If you’re a private practice physical therapist or clinic owner, I’m willing to bet you—and your staff—have had more than one uncomfortable copay conversation at your front desk. After all, copays for physical therapy are often astronomical compared to those for other healthcare services—especially considering that many PT patients require multiple treatment sessions per week. Still, no matter how tough—or awkward—it is to collect those payments upfront, it’s imperative that you take a page from Nike and “just do it.” Because if you don’t, you’re not only compromising your value and your reputation as a healthcare provider, but you’re also slicing into your practice’s bottom line. But before we get into that, let’s rewind a bit and talk about how PTs got in to this high-copay pickle in the first place.
The Troublesome Specialist Category
As physical therapist Jill Murphy explains in this article, most insurance companies “have several categories of co-pays—the co-pay for the primary doctor, specialist and emergency care.” Physical therapists typically fall into the specialist category, and on the surface, that designation makes sense. After all, PTs specialize in the treatment of musculoskeletal conditions. The problem is that insurance plans often require beneficiaries to contribute higher copayments for specialized care—and in the wake of the Affordable Care Act, that problem has only gotten worse. Why? Because in order to keep their premiums low, insurance companies have shifted a greater portion of the treatment cost to the patient—and one of the most obvious ways they’re doing that is through higher copays. “In some cases, the consumer actually pays more than what the therapy provider is actually reimbursed, paying in excess of 100 percent of the cost of care,” Murphy says.
Now, in some areas of specialized care, higher copayments are more of a nuisance than a barrier to patients accessing the treatments they need. For example, as healthcare writer Chris Hayhurst points out in this article, a patient may only see a specialist like an obstetrician/gynecologist once or twice a year. Furthermore, in many specialties, patients historically have only been responsible for copayment on the first visit of a particular episode, with all follow-up visits covered under the initial copay. Matt Hyland, PT, PhD, MPA, CSCS, expands on that point in Hayhurst’s article: “You'd be referred to an orthopedist by your general practitioners—maybe you needed surgery or maybe you didn't—and you'd pay the higher copay. All of your follow-up visits were covered under that single copay. Well, with physical therapy they not only charge the higher copay, they also do it every single time you come in.”
The result? Patients who require therapy treatment two or three times a week—and must pay anywhere from $30 to $60 upfront for each one of those visits—can end up footing out-of-pocket costs exceeding $700 per month. And for many people—especially Medicare patients, who often live on fixed incomes—that simply isn’t in the budget. Unfortunately, that means many patients attend therapy less frequently than they should—or choose to forego it altogether, leaving themselves vulnerable to more serious health conditions and complications. And that, ultimately, leads to higher downstream costs: “...when co-pays become too high, patients no longer attend visits regularly, their limited treatment is unsuccessful and then patients return to their doctors for more invasive and expensive tests and interventions, such as MRIs, injections and surgery,” Murphy writes.
The Crusade for Fair Copays
As Murphy explains in her article, insurance companies have by and large ignored customer and provider complaints over outrageous copays. That’s why, in many states, lobbyists and other PT industry advocates have pushed for legislation to limit copays and/or remove rehab therapists from the specialist designation. Those efforts have been successful in several states, including:
And while those victories certainly are encouraging, the vast majority of PTs still have a lot of work to do. Want to join the fight? Here are a few ways you can get involved:
- Check out the APTA Action Center.
- Pick up your phone or pen and voice your opinion to the legislative powers that be.
- Talk to your company’s human resource department about the benefits of health plans that make physical therapy accessible and affordable.
Additionally, keep in mind that education also is a big part of the copay reduction puzzle. While insurance companies have essentially turned a deaf ear to the copay problem thus far, PTs shouldn’t take that as the final word on this issue. “Education involves both working with patients who are willing to tell their stories and holding direct talks with insurers themselves,” Hayhurst explains. Hyland expands on that strategy, saying, “...what we're trying to do is show the insurance companies how, ultimately, if a patient sees the right provider at the right time—goes to physical therapy when it really can help them—it's going to save the insurance companies money. We're trying to change the paradigm.”
The Slippery Slope of Copay Waivers
Even by the most optimistic forecast, the nationwide adoption of a fair copay policy is still a long way off. In the meantime, many PT practices have defaulted to the precarious practice of waiving patient copays. And while that may ensure that your patients keep coming in for their appointments, there’s a good chance you’ll pay for it—literally—in the long run. Here’s why:
4 Reasons to Avoid Writing Off Copays at All Costs
1. When you waive, you lose.
The revenue you obtain as a result of those additional patient visits often is not enough to make up for the lost copayments. In other words, the more you see those patients, the greater the financial loss your clinic could suffer.
2. When you devalue, you suffer consequences.
By failing to collect the payment you deserve, you’re diminishing the value of your practice—and your profession. And if you do that, how do you ever expect to negotiate for better payer contracts and reimbursement rates?
3. When you disobey CMS, you risk fraud accusations.
Generally speaking, Medicare and Medicaid prohibit providers from waiving copays. This is because, as PT and WebPT Founder and COO Heidi Jannenga explains in this blog post, “doing so misrepresents the true charge for your services.” And although Medicare permits copay waivers in, as Jannenga puts it, “very select circumstances,” in most cases, the exception criteria do not apply. And while the occasional waived copay likely won’t throw up any red flags, consistent employment of this practice could land your practice in hot water. (For more details regarding what may constitute a financial hardship worthy of waived copayment, check out this APTA page.) Bottom line: Unless you want to deal with accusations of fraud, collect copays when they are due.
4. When you waive for third-party payers, you get slapped—HIPAA-hard.
If you waive copays for patients with commercial plans, you could get slapped with fraud accusations—or worse, HIPAA violations. Why? Because, in Jannenga’s words, “...you’re technically misrepresenting charges to the commercial carrier. For example, if you waive a $20 copay on a $100 charge, then you’re basically admitting that you value that service at $80. Thus, the carrier should actually owe you only 80% of $80 (not $100).” Furthermore, as John Yodonise notes in this PT Billing Services article, “HIPAA concluded that free services are likely to influence a patient to receive some other paid services and should be considered a form of remuneration. Since offering remuneration to patients is illegal, waiving copayments and deductibles are illegal.” Again, there are exceptions to that rule—which Yodonise details later in the article—but for the most part, waiving copayment is a HIPAA no-no.
Strategies for Successful Copay Collection
Nobody likes demanding money from people—least of all physical therapists and their clinic staff. After all, money isn’t their main motivation; they live for helping people get back to doing the things they love. But that is exactly why copay collection is so important. PT clinics can only absorb so many losses before they’re too deep in the red to keep their lights on. To ensure they can continue helping patients achieve their goals, PTs must maintain a steady cash flow. And that means collecting copays at the time of service—no ifs, ands, or buts about it. Here are some quick tips on how to make it happen, adapted from this Physician’s Practice slide deck:
1. Create a copay collection policy and procedures guide.
That way, your employees always have a reference to consult when they have questions. In this document, clearly explain your processes and expectations—including the who, what, when, where, and how of collections—and include sample scripts and talking points for all of the various scenarios your staff members may encounter.
2. Give your staff members the tools they need to get the job done—and the money in the bank.
That includes giving them easy access to past due balance sheets and eligibility status information for every patient who comes in for an appointment.
3. Train anyone responsible for collecting copays on the proper protocol for doing so.
Many people are uncomfortable asking for money—even in the context of a business transaction. Conduct role-playing exercises to help ease staff anxiety about the copay collection process, and observe their performance in those situations. Then, offer coaching and suggestions for improvement.
4. Track your staff’s collections performance.
In addition to reviewing monthly, or even weekly, reports with your staff, consider conducting random end-of-day collections checks to make sure everyone’s performing at the top of their game. When your employees know you’re serious about copay collection, they’re much more likely to adhere to your policy.
It could be a long, long time before PTs in most states find relief from the pain of high copays. If you’re one of those unlucky therapists, don’t give in to the temptation to waive copays; after all, you deserve to get paid for the services you provide. Instead, develop an effective strategy for collecting, uphold the value of your profession, and join the fight for fair copay legislation. How does your practice approach copay collection? What tips do you have for fellow PTs? Share your thoughts in the comment section below.