In Ask A Biller Episode 4, Dylan and Maggie answer all of your questions about client payment types: deductibles, coinsurance, and copays. They mention some great resources, which you can find below.
See the full transcript here (scroll to read):
DYLAN: Hi and Welcome to Episode 4 Ask A Biller! I’m Dylan…
MAGGIE: And I’m Maggie. Today we will be discussing Client Payment Types. We will go over deductibles, coinsurance, copays, and out of pocket maximums. Following this video we will host a live event to answer your questions about client payment types.
DYLAN: Remember that if you have questions specific about insurance features in SimplePractice, we offer a class every tuesday at 11am pacific and thursday at 3pm pacific to walk you through getting started.
MAGGIE: We’ve been getting a ton of questions about this particular topic so we’re going to start by simply going over some terms and then we’re going to address some more specific questions that our customers have had.
DYLAN: The first that we we’re going to cover is the type of plan your client has and how to interpret what’s listed on their ID card. This will help you understand how you are going to manage your client’s payments.
MAGGIE: Verification of Benefits is still super important, but at first glance your client’s ID card can tell you a lot of information.
MAGGIE: First, the ID card should have the plan type listed on it. The plan type will inform you whether or not your client is eligible for out of network coverage.
DYLAN:: With plan types there are a lot of acronyms to decode. The most common plan types are:
PPO- preferred provider organization: clients can see INN or OON, they have flexibility to choose whatever provider they want to see
HMO- health maintenance organization: clients can only see providers that are INN and is required to have an assigned PCP (primary care physician) for referrals. Referrals may or may not be required for BH
POS- point of service: like an hmo in that they have to have an assigned PCP and need referrals, but they can see providers that are OON
EPO- exclusive provider organization – can only see docs that are INN but they don’t need referrals– no PCP
DYLAN: Your client’s ID card may also help you determine whether or not your client has a copay for office visits. Every ID card is different– there is not standard to expect, but many will have a small summary of their coverage.
MAGGIE: On this card preventative indicates that there’s no copay for medical services that are considered preventative (annual check up, annual lab work, mammogram, etc). ER= emergency room and OV= office visits. You never want to just go off of what is on the card, you always want to verify coverage based on CPT codes, but this is a great place to start
DYLAN:Other language you can expect to see on the client’s ID card are shown on this slide
So the most notable here are pcp is primary care provider, coin is coinsurance and ded is deductible. HDHP is high deductible health plan and there will be som addition acronyms for the pharmacy
MAGGIE: Now let’s get into the different payment types you can expect to see. We are going to be covering in-network examples. These scenarios will apply to the payers that you are panelled with. The first and easiest one to understand is copays
MAGGIE:A copay is basically a cover charge to get in to see a provider. This will cover the charge for the office visit, but might not cover additional services provided during the appointment. If there’s any kind of additional testing and bill other services, it will be a separate charge that a copay might not cover. They are generally broken down by specialist and pcp, pcp usually being a cheaper options. Collect at time of the visit, and bill the insurance your full private fee
DYLAN: Let’s say your session fee is $100, and your contracted rate is $90. You checked with the payer and the client has a $40. You will collect $40 up front and then bill the full $100 to the insurance. They will reimburse you the additional $50–to total $90 and youl will write off $10
MAGGIE:The next payment type to consider is deductibles
DYLAN: A deductible is a set amount that your client pays out of pocket towards for all of their services
Copays generally don’t go towards a deductible
It’s important to know your contracted rate so that you know what to charge a client. Payers won’t share this information with your client so clients with deductibles usually have no idea what they are going to have to pay for a particular service walking in the door
Doesn’t roll over at the end of the year
MAGGIE: For example, your client has a $1500 deductible, Your session fee is $100 and your contracted to rate is $90. The client will pay you $90 directly. You will submit a claim for $100 to the payer. The insurance payer will keep track of their services not their actual payments, you are are responsible for making sure that these fees are collected. You will write off $10. This is how billing this client will work until they’ve accumulated a total $1500 of services.
MAGGIE:Then, coinsurane will kick in. Coinsurance is the predetermined percentage that the client will owe.
DYLAN: Your session fee is $100, your contracted rate is $90. The client met their full $1500 deductible, and the payer told you their coinsurance in 80/20
This means that the client will owe you $18 (20% of the contracted rate) and the payer will reimburse you $72 (80% of the contracted rate) You will write off $10
DYLAN: Back by popular demand– Charlie is here to help you understand the different payment methods your clients might throw your way
CHARLIE: Hi there,
Everytime Charlie Chats rolls around, we decipher another item in the odd language of insuranceese.
This week on Charlie Chats we’re going to talk about Health Savings Accounts, Flexible Spending Accounts, and Health Reimbursement Accounts, aka HSA, FSA, and HRA
What do these acronyms mean, and why do you need to know them? These are all different types of payment methods offered by employers and payers, in an effort to curb the cost of spending on health care. These accounts usually compliment plans with high deductibles, where the client would have to pay a considerable amount out of pocket.
First, let’s talk about the HSA.
A Health Savings Account is essentially a debit card for health care expenses. Your client and their employer may contribute pre-taxed money into this account to go towards qualifying care-related expenses. Only certain types of coverage allow a supplemental HSA. Your client should have a card for their HSA, and they will have ownership over this account. It will not be directly connected to the payer they’re covered by– it is entirely supplemental to their benefits. You’ll charge this card just like you would a debit or credit card– you can use SimplePractice’s super convenient payment method, Stripe!
Flexible Spend Accounts are owned by the client’s employer but are held in the client’s name and both parties can contribute pre-taxed dollars to the account. Ownership is what distinguishes this type of account from an HSA. There’s also more flexibility about the type of coverage a client can have. The plan doesn’t have to meet specific qualifications, but the expenses must be health related. FSA vendors will have a list of applicable expenses. Your client should have an FSA card that can be charged in Stripe as well.
Last but not least, the HSA.
A Health Reimbursement Account is different from the first two, in that your client won’t have a card that they can charge services to. The account generally must be integrated with the client’s insurer and reimbursements will be issued only after services have been billed and processed. The account will be held in the client’s name, but deposits into this account are made only by the client’s Employer. Clients may need to submit invoices and EOBs to their Human Resources department in order to be reimbursed for out of pocket expenses.
I know this is a lot of information, so if you need a refresh, head to our blog, where we’ve provided a downloadable list with everything you need to know about HSA, FSA, and HRA.
I hope that makes the insurance part of your practice a bit simpler.
So, until the next Charlie Chats, here’s Maggie and Dylan!
MAGGIE: Thanks for clearing that up, Charlie! The last element of payment types that we’re going to cover is the Out of Pocket Maximum
DYLAN: And for once, this is exactly what it sounds like. Every benefit plan will have an absolute maximum on the amount that the client will have to spend of their own money. OOPmax amounts can vary a ton depending on the client’s coverage. In Network Copays, deductibles, and coinsurance payments all go towards the in-network OOP max.
MAGGIE: On this topic, Cheryl from our Facebook community added that she had trouble with
“Knowing when a client has met their out-of-pocket maximum. I’ve had this happen a few times and the only way I found out was when reimbursement went to my full contracted rate. By the time that happened, my client had paid sometimes up to four copays they didn’t need to pay and I’ve had to refund those funds.” -Cheryl
MAGGIE: Since you might not be privy to the other health care expenses your client is accumulating, the best way to keep track of this will be by checking VOB before you start treatment. That way you’ll have an idea of where the client is/ how much they have left on their OOP max or deductible.
DYLAN: We also recommend periodically checking in with the payer if this is a client that you have a long-term treatment plan with. We can’t guarantee that this won’t happen, but if the payer has an online portal, it’s good to keep track of this info and keep record of in on the client’s overview in SP
MAGGIE: We had another question from Maria regarding Kaiser Deductible
I don’t understand why Kaiser deductibles show up as denied. I was told it’s a clearing house issue, and that it’s being worked on, but as a therapist, I like to understand the rationale behind things!
MAGGIE: Maria, this is great question. I can definitely appreciate that a lot of customers are concerned about this. What happens when you see a denial status that should say dedcutible is that our automated system is interpreting a $0 payment from the payer as a denial–when it’s actually a $0 payment because the client owes you their deductible. When this happens, you will need to go through and add the write-off amount for each session so that the full session fee is accounted for and then system will recognize that this is a deductible and update the status automatically.
DYLAN: That’s all we have for you today. Thanks so much for tuning in. If there’s anything that you still have questions about on client payments, we will hosting a live event two weeks from today on May 17th. We will be sharing the link to register for that webinar here on out blog.
MAGGIE: And remember, If you have questions about your SimplePractice account, we offer a bunch of resources and live classes to help you out. To sign up for a class go to support.simplepractice.com –while you’re there take a look at some of the videos and guides that we’ve put together to make using our software a breeze.
Also, if you like the shirt i’m wearing and want to get one for yourself, check out the simplepractice swag shop! There are plenty of great items for your friends and family–and the best part about it is all the proceeds go towards Ocean Park Community Center, a non-profit organization headquartered here in our home of Santa Monica to service homeless individuals, victims of domestic violence, at-risk youth, indigent Veterans, and people dealing with severe physical or mental illness or substance abuse.