Human services providers across the country are facing ever-increasing challenges when it comes to managing commercial insurance, especially as it relates to consumer payment obligations. Shifting reimbursement models paired with provisions under the Affordable Care Act (ACA) are increasing the amount of money consumers must pay for care, and insurers are pushing payment obligations back to the members: your consumers. In order to stabilize their organization’s financial health, providers must address these challenges directly.
In addition, consumers are presenting a wide variety of insurance coverage and benefits, often making reimbursements dicey because not all consumers are insured the same way. Often times, consumers seeking behavioral health services such as medication management or psychotherapy have commercial insurance coverage, however benefits, copayments and deductibles look different for each person, depending on the type of plan(s) they have.
Because of the complexities of commercial insurance alongside changing payments models, your team needs to be prepared. Issues arise when behavioral health organizations don’t effectively manage the consumer’s payment obligations. This can mean copayments aren’t collected at the time of service or deductibles aren’t being met, which causes organizations to lose money and can dampen their reputation with commercial insurers. Someone must absorb these costs and many times it is going to fall on you, the provider. It’s important for organizations to not only consistently collect copayments, but proactively implement policies and procedures that address the unique specifications of each consumer’s healthcare coverage.
The risks involved when you don’t have a payment policy in place are high. For behavioral health organizations to maintain financial stability in a value-based care setting, providers must have consumer-centric policies and practices in place to properly manage the financial responsibilities of consumers seeking care. Having a consumer-focused policy that addresses potential refusal of care should be developed in conjunction with clinical leadership. Engaging your care teams initially in policy formation ensures the best interest of the individual is at the forefront.
For example, a consumer-centric policy may call for denial of service if the individual cannot cover their financial obligations, and this decision should include clinical leadership. It’s important to develop policies that incorporate care delivery and financial commitments and then sticking to them.
Payment conversations can be challenging for your team and knowing how to execute policies requires education. Enforcing financial policies that address the needs of your consumers, while also prioritizing the financial needs of the organization will help all involved in the long run. Your organization is in the business of caring for those in need, but it’s also a business that needs cashflow to keep the doors open.
The financial viability of your business depends on how effectively you manage consumer payment responsibility. So, how do you do that? Here are some key tips:
1. Develop your plan. First and foremost, you must develop a policy that best fits your organization and the individuals you serve. Have a plan in place and make sure your staff is sticking to it. As mentioned previously, engage your clinical team in developing these policies. This helps prioritize both the consumer and the well-being of your business. This may sound elementary, but many organizations are operating without a formal policy in place.
2. Train your team. In particular, the staff managing the front desk must be properly trained to have payment conversations with consumers. This can be a difficult conversation and can take some practice. Arm your team with the talking points and resources they need to make sure the services you provide are covered. If a consumer is unable to pay their portion of the service charge, the front desk employee must know the proper steps to take according to your policies, such as setting up a payment plan. In addition, make capturing payment at the point of service as simple as possible for your team. This will help ensure fees are being collected.
3. Analyze coverages. As mentioned, there are a wide variety of healthcare plans on the market. Behavioral health organizations need to start mirroring what physician practices do. They need to know the individual’s current insurance status: What insurance plan do they have? What is covered and what is not? Have they met their deductible? Is the practitioner credentialed with the insurance? It’s more than just running the insurance and seeing if they’re covered. The more your team knows, the better they can advise your consumers and deliver great customer service.
4. Communicate, communicate, communicate. Arguably the most important task in setting up a plan is to communicate. Your financial policies need to be shared with your consumers. Every current or future client should understand your financial obligation policies. You can’t overcommunicate this. If they don’t know, you are putting your organization at risk and setting your team up for a difficult conversation. Effective ways to notify clients include email, direct mail, posting policies to your website, placing signage at the front desk and making it a discussion during the check in process. Clearly define the consequences of new said policy and stick to them.
5. Seek outside expertise. If you aren’t sure what will work best for your organization, get help. You can’t afford to operate otherwise. Having consulted a wide variety of healthcare organizations regarding financial policies, I know an experienced, outside perspective can be incredibly beneficial. Get the help you need to review your current protocols and uncover where additional policies and procedures could benefit the organization, your staff and the consumers you serve.
As I travel the country meeting with human services providers, it’s clear this type of consumer-related issue is increasing. Without a financial policy in place, your technology and other tools for managing payment will be underutilized. Look at each consumer’s coverage and financial obligations though a different lens; the one-size-fits-all approach isn’t sustainable anymore as regulatory changes take effect.
While the consumer is the top priority, ensuring the financial stability of your business is what allows you to continue providing services to your community. Minimizing potential impacts can be as simple as putting consumer-centric policies in place for your non-Medicaid populations.