Is your patient dealing with high out-of-pocket?

Make it clear you're there to help

More often, outpatient surgery staff members find themselves in the unenviable position of telling patients about out-of-pocket responsibilities running into the thousands of dollars.

Offering patients an immediate discount if they pay upfront is one good approach, according to Gail Melingonis, director of patient access at the University of Connecticut Health Center in Farmington. "Let's say a self-pay patient is going to have surgery, and their out-of-pocket estimate is $10,000. We'll give them that dollar amount, and say, 'If you pay us today, we will give you a 30% discount,'" she says.

Financial counselors must be clear that the $10,000 is an estimate of charges, and that there might be additional charges if procedures are added and that the 30% discount would apply to the entire balance in that case, says Melingonis.

If an insured patient has a large unmet deductible, of $2,000 for example, financial counselors do try to collect the entire amount. If the patient says they will not pay anything on the deductible, procedures or surgery isn't held up, however, says Melingonis. "If the patient says they can't pay the entire deductible, we ask them how much they would be comfortable with. We aim for at least half," she says. "If they offer us $20, we may ask for more. If they can't, we would take whatever they offer."

More accurate estimate

If self-pay patients can't pay an account balance, financial counselors meet with them to see if they qualify for some type of assistance, whether a public program or the hospital's charity care program.

"If they really don't qualify for anything, we tell them that we could set up a payment plan," says Melingonis.

This step isn't done at the point of service, however, because at that point, the actual charges aren't yet known, she says. "We would rather have them get the final bill before we set them up on a payment plan," says Melingonis. "Otherwise, we may over or under estimate what the monthly plan amount should be."

When financial counselors quote a price to a patient, they rely on the CPT code for the procedure that the doctor is planning to perform, she says. If the patient is having a knee arthroscopy, for instance, financial counselors estimate charges based on the CPT code, the fee schedule, the facility fee, and the number of hours the patient will be under anesthesia.

Based on that information, a self-pay patient might be quoted a price of $7,000, but that amount might change because the physician ended up doing a repair during the procedure, she says. "Some patients will call us very frustrated and want to know how much they're going to get charged," says Melingonis.

Financial counselors contact the patient's physician's office to find out exactly what they are planning to do, which gives them more accurate information to base the estimate on. "We try very, very hard to give as much information as we possibly can and make the patient feel that we are helping them," says Melingonis. "They are already being hit because they have a medical issue. I don't want to hit them again with a financial issue."

Deductibles explained

Financial counselors offer to contact the patient's insurance company to find out how much of the deductible has been met. In some cases, patients don't even realize they are responsible for a large deductible before insurance will consider paying anything at all, Melingonis says.

"We find this comes up most often at the beginning of the year, or when insurance takes effect," she says.

Occasionally, an overwhelmed patient will ask a financial counselor, "Why is it so expensive?" In this case, says Melingonis, staff state, "These are deductibles your insurance company set. If you went to any other facility or were treated by another physician, you are still going to have this expense before insurance will consider paying anything."

When patients express dissatisfaction with their insurance policy, they also can be advised to speak with their employer's human resources/benefits manager about their plans.


For more information on helping patients with out-of-pocket responsibilities, contact:

  • Gail Melingonis, Director of Patient Access, University of Connecticut Health Center, Farmington. Phone: (860) 679-4542. Fax: (860) 679-1636. E-mail: