What are patient cost shares?
Patient cost shares are the portion of medical costs that a patient is responsible for paying out of pocket. They can vary depending on the insurance plan, but they typically include deductibles, co-pays, and co-insurance.
The three main types of patient cost shares:
Deductible: The amount a patient has to pay out of pocket before the insurance company starts paying for any services. It is usually a flat amount and resets each policy year.
Co-pay: A set dollar amount a patient pays for specific services at the time of service. It is not associated with the deductible and may or may not apply towards the deductible.
Co-insurance: A percentage of the total charges for a service that the patient is responsible for paying after the deductible has been met. It is usually applied after contractual adjustments are made.
One of the most common patient billing disputes comes from a rule meant to help patients. Screening colonoscopies are covered at no cost share under the Affordable Care Act, but if the physician removes a polyp during the exam, the procedure becomes diagnostic, and the patient can get a bill for a visit they were told would be free. Modifier 33 for commercial plans and modifier PT for Medicare are meant to preserve the screening benefit here, though plans apply them inconsistently and Medicare is phasing out the coinsurance on converted screenings gradually through 2030 rather than waiving it outright. Explaining that possibility before the procedure, not after the statement arrives, is one of the patient-communication steps gastroenterology billing services handle alongside the claim itself.
Why are patient cost shares important for medical practices?
It is important for medical practices to understand patient cost shares so they can collect the correct amount from patients. If a medical practice does not collect the correct amount from patients, they may end up having to write off the debt. This can be a significant financial burden for medical practices.
How can medical practices identify patient cost shares?
Patient cost shares can be identified on Explanation of Benefits (EOBs) and Explanation of Remittance Advices (ERAs). EOBs are statements that insurance companies send to patients after they receive care. They explain what the insurance company paid for and what the patient is responsible for paying. ERAs are statements that insurance companies send to providers after they receive a claim. They explain how much the insurance company paid for the claim and how much the provider is responsible for collecting from the patient.
Resources for medical practices
There are a number of resources available to help medical practices learn more about reading EOBs and ERAs. Two free resources that viewers can use to learn more about reading EOBs and ERAs are freemedicalbillingtraining.com and the AMA's document on understanding electronic remittance advice.
In addition to the above, here are some additional tips for medical practices:
Make sure your staff is trained on how to read EOBs and ERAs.
Have a system in place for collecting patient cost shares.
Offer patients a variety of payment options.
Be clear with patients about their financial responsibility.
By understanding patient cost shares and taking steps to collect them correctly, medical practices can improve their financial health.
