Paying it backward
On the new trend in healthcare payment creating yet another burden for patients
There’s a new trend in healthcare billing: pre-pay, otherwise known as having a “credit card on file.”1
I find the trend abhorrent.
Medical billers are promoting this practice because of the high number of unpaid bills that end up in collections. I fully support being paid for our work. Who doesn’t?
And I get that the billers want to help. But I think it’s a bit self serving on their part, since they get a percentage of the “take” (so to speak) and they are the ones who make the collections (i.e., collections are extra work on their part). So essentially, they get more and do less work.
But let’s talk about what else is happening.
First, I think that it’s odious to ask for money in advance because it cements the idea that you must pay, regardless of how terrible the service is. I know there are a lot of gray areas here. There are well-off patients who receive excellent care but are cheap so will complain to get some dollars knocked off their bill. And there are patients who are dirt poor but diligently pay every bill, without looking at if maybe they were overcharged.
On that topic, I think medicine is one of the only industries where clients (i.e., patients) cannot get their money back should they experience a medical error or other problem. If I have a problem with my car and the mechanics make it worse, they assume financial responsibility for getting it right. Not in medicine.
You’d have to pursue a lawsuit to get compensated. And an apology? To quote an old friend, that’s rarer than hens’ teeth.
My malpractice lawyer has told me more than once to never apologize. His reasoning is sound. If I apologize for something that went wrong on my watch, and a patient decides to sue me, my apology can be used against me.
There are so-called “apology laws” to help prevent harm in such cases, but most protect expressions of regret not error disclosure. There are some states with “total protection” apology laws. These supposedly allow doctors to apologize for a mistake without being concerned that it can be used as evidence against them.
But most of my colleagues (and my lawyer) believe an apology actually increases the likelihood of a lawsuit, so most of us keep our mouths shut. A survey of U.S. physicians published in 2007, showed that nearly all of the physicians who responded (320 out of 338, or 95%) felt obligated to tell patients about a mistake; however, only 41 percent of these same doctors had actually disclosed minor harmful errors to their patients; only 5 percent disclosed major errors.2
Nevermind that the research shows that a physician apology “can have tremendous therapeutic potential for both parties. Apologies can reduce anger, promote healing, and repair damaged relationships.”3
I’m very up on the laws in my state and have my lawyer on speed dial, so to speak. Therefore, I’m not afraid to take ownership where warranted. But I digress.
The thing is, because of these quirks of medicine—a patient not being able to get their money back and apologies in short supply—patients are treated more as peasants in the medical kingdom to whom we give little and from whom we extract much.
Yes, there are other businesses, especially in our online economy, where your credit card is on file. But in the cases I know of, the terms are clearly spelled out and you can cancel at any time.
In the healthcare economy, the front desk person is given all power to demand the card be handed over or “we won’t see you today,” which is emotional blackmail to someone who is already feeling vulnerable. There are no carefully considered terms handed to the person. No discussion. No other options.
And what if they have only a debit card to keep “on file”? I don’t think any medical office should have such access to patient bank accounts, carte blanche so to speak.
Providers add the disclaimer that the patient will be “notified via email” in some amount of time before the money is deducted, as if that will make it all better. Such disclaimers should read, “we’ll take out whatever amount of money we need from you but we’ll let you know two days in advance so you better be ready at any time for any amount even if it puts your account in default.”
Recently I suffered a computer outage and didn’t have access to emails for two months. I missed important deadlines as a result. In such a scenario it would have truly complicated matters had I also learned (after the fact) that my financial accounts were overdrawn because of a missed email.
Also, what happens if the biller takes out more than is due? We all know how much time it takes to get business offices on the phone (personally) and our questions answered. To me it seems unfair to put all this on the shoulders of the patient, which is always where it ends up.
I won’t allow these things to take place in my practice.
Why can’t we offer to the patient the option to pay after the appointment, if we must demand payment. Why does it have to be in advance? Why can’t we offer a cash option? Or a retainer, like with lawyers. I believe it has to do with the way our billers own us physicians, and that has to do with how doctors have let the business side of healthcare get away from them.
Us physicians believe we’re good at anything we do, and yet it is a little known secret that many physicians are terrible at business. We think we’re making wise decisions when we allow our trusted billing offices to dictate what happens in our practices. We think we’re being smart with money when we hire those billers in the first place.
I’m not saying most aren’t being smart, I’m just saying, as one who grew up around doctors of many kinds, that physicians are often not the brightest bulb in the pack when it comes to finances. Why do you think so many of us have sold out to the big corporations to run our practices?
I believe clients, i.e., patients, should have full control of their own money, including when to release it. If they don’t want to put down a credit card, they shouldn’t have to. If they want to pay cash in advance, they should be able to.
I have a lot more to be said about healthcare finances, from the patient perspective, but I better get back to seeing my patients. That’s where my real joy is.
Please share your own experiences. Maybe together we can change the system.
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The information, including but not limited to text, graphics, images and other material contained within this Substack, are for informational purposes only. In addition, the physician who “writes” material for this Substack is a product of the author’s imagination. Even if she were real, however, no material on this site is intended to be a substitute for medical advice, diagnosis or treatment, or billing practices. Always seek the advice of your physician or other qualified health care professional with any questions you have regarding a medical condition or treatment and before undertaking a new health care regimen. Never disregard professional medical advice or delay in seeking it because of something you’ve read on this site. And eat your fruits, vegetables, legumes and whole grains. (Dr. Sarah had to add that last sentence. She likes having the last word.)
Kaldjian LC, Jones EW, Wu BJet al: Disclosing medical errors to patients: attitudes and practices of physicians and trainees. J Gen Intern Med 22:988–96, 2007CrossRefPubMedGoogle Scholar
https://jaapl.org/content/early/2021/05/19/JAAPL.200107-20 (Accessed 1/26/2024)