How to manage copays under the Affordable Care Act

Keith Lilek

Now that the Affordable Care Act is in effect, many people have health insurance for the first time, and even more have switched to a new carrier. Insurers that your office may be very familiar with will have new policies in place for patient copays and deductibles. Along with all these changes, many preventive services must now be offered without copays, and new “out-of-pocket maximums” (OPMs) mandated by federal law mean that some patients will be liable for copays while others are not. Because of this confusion, millions of copays will go unpaid, and effective copay collection will be crucial for all healthcare billing services. For providers of durable medical equipment (DME) and home medical equipment (HME), staying current on best practices for copay collections may be the key to remaining profitable in the new healthcare economy.

Copays add up

If a typical medical appointment copay is $20, and a physician sees 25 patients in a day, that adds up to $500 each day in copays; with more than 200 workdays in a year, the annual total is over $100,000. Putting solutions in place to make sure all patients meet their copay obligations is fundamental for maintaining a solid financial basis for every medical practice. Collecting the copay when the patient checks in for their appointment is the goal that all of these policies should strive for, since this saves the time and expense of sending out bills.

Communicate effectively with patients

The first step is to give all patients a written copy of payment policies when they first have contact with your office. The timing and tone of such policies should be handled with sensitivity, since patients are consumers who can exercise choice. It’s important for a practice to convey the message that it is primarily interested in the patient’s well-being, while also being attentive to financial matters. It’s helpful to have patients sign and date a copy of your payment expectations, and to place a copy of this form in their file. You can also feature a prominent sign at the front desk that states that the copay is due at time of visit.

Prepare reception staff

A provider’s support staff should collect insurance information from a patient when he or she calls for an appointment. Verifying coverage and type of visit before the patient comes in allows billing specialists to check ahead of time for the individual’s required copay. Even if the insurer hasn’t changed since a previous appointment, the copay may be different for each visit. Furthermore, in some instances a preventive visit (requiring no copay) may turn into a different treatment category if a problem is found. In such instances, a copay may need to be levied after the fact. The American Congress of Obstetricians and Gynecologists suggests posting a sheet in the reception area and the billing office areas with the most common preventive care codes, so that all staff are clear on when they should request copays.

As a general rule, however, a patient calling for an appointment should be politely reminded that if a copay is due, it must be paid at the time of the appointment. For front desk staff who feel uncomfortable asking for money, you can offer scripts for them to follow. For example, you can train a representative to ask, “How would you like to pay your copay today?” Also, make sure that your office easily accepts all forms of payments: Have enough cash on hand to make change, and also offer options to pay with debit and credit cards, as well as checks.

A change in culture is necessary

While optimal billing procedures sometimes include turning patients away if they are unable to pay the copay at the time of check-in, providers may wish to add some variability in to this policy. It may not be advantageous to turn away patients who are presenting with an urgent medical need, and some diplomacy and re-education may be needed for those patients who have a long-standing relationship with the practice. The American College of Physicians reports that while requiring copays to be paid at the time of the visit can cause some upset among patients, this problem decreases over time as patients become accustomed to the policy.

Collecting copays is not at odds with the practice of healing; instead, maintaining the financial well-being of your practice will enable you to keep your doors open to more patients, and to make a difference in the world.


About the Author

Keith Lilek has solved A/R problems for hundreds of clients and delivered hundreds of seminars on cash management, covering the skills needed to successfully reduce collection costs and increase cash recoveries. Keith continues to teach clients how to properly manage the accounts receivable cycle.