One change reduced patient receivables from $20K to almost $0 – Transforming the front desk experience



We’ve all been there before; late to a doctor’s appointment, having new insurance but forgot the card, patient history to update and, oh yeah, I owe the office a few bucks. One of the most interesting aspects of working on the business side of a medical practice is when you become a customer of a practice you’re not affiliated with. The recent office visit scenario above got me thinking about how we can do better.

No one likes being ignored, treated tersely or abruptly.  Most of us respond positively to being acknowledged and find reassurance when you feel your medical accounts are being handled professionally and accurately.  An office that takes the time to explain a patient’s financial obligations is ahead of the game. One that actually can estimate the amount due and secure payment before the provider is seen is the equivalent of hitting a home run.

Realizing it’s Time for a Change

For years, one of my long-time clients continually tweaked their processes related to patient collections. They did all the right things in hopes of reversing the decade long pattern of increased account balances. This client was doing everything they could to meet the challenge. They performed eligibility checks and  added financial verbiage to their appointment reminder calls. They focused on collecting patient balances at check-in. They even had the ability to provide a statement on demand. In an effort to stem bad debt or excessive delays in payment, they even implemented a protocol requiring a deposit be made to cover a portion of the anticipated patient balance.

While these changes resulted in an increase in collections at the time of the visit, the underlying issue of increasing patient balances persisted. Proactive outbound patient calls were initiated and the practice finally saw an improvement to the outstanding balances. The additional labor expended to call patients  resulted in a 10 percent reduction in the month-to-month patient receivables. While this covered the cost of the additional labor, the results required continual calling and did not significantly address an ever-increasing volume of patient statements.

An unintended consequence of these policy changes was an increase in the number of accounts requiring a refund due to over-collection. Suddenly the cost of issuing patient refunds began to eat up all the savings the outbound patient calls had secured. In addition, the relentless pursuit of collecting payments made the office visit uncomfortable for both the patient and office staff.

Out with the Old…

This client decided to implement the Instamed Signature on File work flow, in an attempt to find a solution to the growing outstanding patient balance issue. The decision required a staff member to obtain patient authorization to charge a bank card on file for the balance due.

In order to allow the front desk staff the time and opportunity to obtain a signature on file, something had to change. It was already uncomfortable asking the patient to pay their balance, let alone having their credit card on file to run a payment. The answer was to move the pre-visit functions performed by the front desk staff to the billing staff. A universal complaint is the front desk staff picked the wrong insurance, failed to verify eligibility or failed to obtain referrals and authorizations required for payment. Now we had a chance to address this issue too.

We collaborated with the practice staff and the Instamed implementation team to develop a new front-end process. The billing staff began to review the scheduled appointments several days in advance. This review involved running eligibility and creating a rough patient responsibility. The estimated amount due from the patient is based on the benefits information coupled with an average cost per visit for the specific appointment type and payer. The biller is able to ensure the correct payer, ID#, group # and co-pay amount. The biller is also able to review the referral and authorization information and make requests as needed from the office. It is not unusual for the biller to call the patient prior to the appointment to verify information needed to complete the pre-visit activity and generate an estimate of patient responsibility.

Conveying the Correct Message

Next came the difficult step; asking for the patient’s authorization to use their credit card to pay their balance automatically. If your initial reaction is that you wouldn’t trust this process to be accurate: you’re not alone. We had to educate the office staff on all  the benefits and safeguards in place. Along the way, the staff acquired a greater appreciation of how important communicating the process to the patient is. The staff was surprised to learn that having the signature on file was a huge benefit to patients, saving them; time, money and aggravation.

We prepared scripts to help staff articulate the message clearly. More importantly was for the staff to get into the right mindset to have the conversation in the first place. We found it essential for the front desk staff to believe the patient was receiving quality service that addressed their basic needs, not unlike nourishment (restaurants) or shelter (hotels). Looking at services this way, made asking for payment (or more accurately, the promise to pay) from patients an easier task.

When the process is fully explained and the necessary tools are available, the patient has much more visibility and control over their account than ever before. They can avoid paper statements, incorrect payments, checks, envelopes, time, etc. Framing the patient conversation with these facts paves the way for acceptance. While not every patient will agree, you will be surprised by the number of patients that embrace the solution. Patients questioning accuracy and security will be relieved to know that the system is completely secure (more secure than a swipe terminal) with many checks and balances in place to limit the amount of the charge and control the timing of payments.

On the back-end, we replaced the traditional patient statement with a receipt from the Instamed system. The patient’s credit card payment is processed within a week of the patient receiving the Explanation of Benefits (EOB).

Good Things are Worth Waiting For

The first few weeks of implementing the new process were a bit stressful, but the entire team pulled together. By the end of the first month the financial impact was felt, and after seven months, the financial impact was striking. This practice saw their monthly statement volume plummet 80 percent –  from 250 statements to 50.  The total Patient A/R also dropped from $20,000 to nearly zero. An unanticipated benefit was the change in the cumbersome refund process. Using the new process resulted in the elimination of over collecting. It also simplified the refund process in that any refunds due could be processed to the patient’s credit card without incurring mail or check generation costs. As an added bonus, the days in accounts receivable also dropped from 32 days to 28.

The financial benefits are measurable. This practice is still working toward a patient survey, but the anecdotal evidence is very promising. Feedback from the front desk staff is now that many established patient visits are already signed up for signature on file. The check-in process is much less stressful than before. Taking away many of the financial conversations has allowed time to greet patient’s. New patient registration is finally approaching the welcoming intake process envisioned when the program started.

Patients have been eager to get rid of paper statements. While few had already embraced paying their bill online using the patient portal, we were amazed at how willing the patients were to have automatic payments, with the assurance that their payment is based strictly on the EOB they receive from their insurance company.

The practice is eagerly awaiting an even greater opportunity to leverage the additional resources freed up each time a patient is added to the signature on file process. Future plans are being made to deploy these new resources on patient engagement including; personal set-up and training on use of the patient portal, pre-population of the medical record and assistance with referrals and authorizations. All-in-all this is a win-win-win with the patient, the front office and the billing staff, all receiving tangible improvement to a critical process for every medical practice.


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I am the President of Physicians Reimbursement System (PRS, LLC). My business journey started in the microfilm industry nearly forty years ago. I have worked in the business services sector for nearly forty years and have a keen appreciation for human capital (our employees) and production processes. In 1988 I ventured into the medical billing field and have seen the industry move through several milestones, beginning with the introduction of mandatory CPT codes, mandatory electronic claim submission, introduction of NPI, 5010 conversion, ICD-10 replacing ICD-9 and literally thousands of payer policy changes. I have always had an affinity for formulas, calculations and numbers. As a result, I am able to deconstruct and decipher billing operations from revenue cycle reports. Nothing satisfies me more than being able to provide revenue cycle services that deliver a bona-fide return on investment. Over the last two decades, my clients consistently increase revenue far above the cost of our services.