Time of Service
T/F: If the office visit is a covered procedure, additional procedures are always included.
False. Based on the insurance plan, a separate cost may be applied to additional procedures.
T/F: Having insurance means the patient pays nothing today.
False. Insurance can cover an office visit or procedure and still apply all or a portion of the responsibility to the insured.
Which phrase is a more effective explanation for a patient: "Your insurance requires this.." or
"Based on your plan.."
"Based on your plan.."
Why? It feels personal. Your specific coverage. It is tailored, not imposed and it implies structure, not punishment. "Your insurance requires this" sounds like a hard rule, possible denials.
Patients don't argue with their plan as much as they argue with a requirement.
There is a financial key term that must be present in your payment transaction note when collecting for additional procedures. What two options or key terms are these?
"Flat Fee" or "Allowance"
A patient at check-in is missing an updated estimate for allergy injections under their 2026 benefit plan. What's the most appropriate way to handle this?
Send a message requesting an updated estimate or VOB for shots in the Allergy STAT VOB channel.
A patient at check-in tells you they left their wallet at home, so can't pay their copay. How do you respond?
Model Answer: I understand - that happens sometimes. If you're unable to pay today, we'll need to reschedule the visit, but don’t worry I can help you find the next available appointment.
*Maintain compassion and control*
T/F: If the out-of-pocket maximum has been met, it's a guarantee the patient won't owe anything after completing a visit at the office.
False. The patient will not owe for covered procedures. If a non-covered service is provided or if medical necessity is not established, the patient will owe for the visit.
Fill in the blank: "Today's amount due is an ______. A ______ will be filed to your insurance for final determination of benefits and your financial responsibility"
"Today's amount due is an ESTIMATE. A CLAIM will be filed to your insurance for final determination of benefits and your financial responsibility"
What should be documented if a patient leaves without paying at check-out?
A patient is here for their pre-op appointment and they have not paid their deposit. The Surgery VOB form on file has a balance due for surgery and shows no past due balance at the time verification was completed. You notice the patient now has a $50 balance open. What would you do?
In your own words, what does "file first" mean and when is this done?
Model Answer: If we "file first", no payment is collected at the time of service. Instead, a claim is filed first for the insurance company to make a final decision on benefits and patient's cost. This process is followed when we expect the insurance company to fully cover the visit.
How do you explain a deductible without using insurance jargon?
Model Answer: It's what you pay first before insurance helps cover the visit.
The patient asks why today's visit has an increased cost after having a scope. What is your response?
Model Answer: "The provider determined the scope was necessary to manage & treat your symptoms. Based on your insurance plan, you must meet your deductible before insurance will start to cover costs. If there is any difference after the claim is processed, you will either receive a refund for the credit or a statement with any remaining due."
A next day appt was mistakenly scheduled for a patient in collections. When you inform the patient at check-in, they state they are ready to pay now so they can see the doctor. What is your response?
Model Answer: "Absolutely, I can help with that. Please contact Frost Collections at 855-287-7043 to make your payment."
Patient asks if their hearing test will be an extra cost after you just reviewed benefit details and determined you don't need to collect a flat fee today. What is your response?
Model Answer: "There is not an extra cost today, but we will need to file the claim to your insurance for final determination. You will receive a statement after the claim is processed if an extra cost applies based on your benefits."
A patient at check-out wants an alternative to not paying for today's scope. How do you respond?
Model Answer: Yes, I can help with that. Alternatively, you can provide consent to store your card securely in the system to be charged only after insurance processes the claim. You can provide written communication to the office at any time after this claim processes if you want to remove it afterwards.
Insurance says "covered", patient says "then why do I owe?" What's a good explanation?
Model Answer 1: A covered service does not mean $0 due. Based on your insurance plan, they apply a fixed rate to the visit which is your copay.
Model Answer 2: A covered service does not mean $0 due. Based on your insurance plan, they require you to pay a certain amount before they start to cover any of the cost.
A patient doesn't understand why they owe after meeting their deductible. Reword this in patient-friendly language: "Yes, your deductible is met, but co-insurance applies."
Model Answer: "Yes, I see you have met your deductible. Based on your plan, you're still responsible for a piece of the cost until you meet your out-of-pocket maximum. Since the out-of-pocket is not met, your insurance will cover 80% and you are responsible for 20%, this is your co-insurance."
What is the difference between collections debt and in-house bad debt?
COLLECTIONS: Bad-Debt referred to a third-party collection's agency, Frost Collections. This must be paid to Frost directly.
IN-HOUSE BAD DEBT: Bad-Debt adjusted internally in our system. This should be paid to our office directly.
Patient asks why they still owe for allergy shots when they have met their deductible. The billing alert or VOB on file says the estimate for shots is a $12.45 copay. How do you explain this?
Model Answer: "The allergy shots are estimated towards your copay, not your deductible. The copay is applicable until your out-of-pocket maximum has been met. Since you still have an out-of-pocket remaining, there is a copay due today."
T/F: A patient completed their post-op visit and the check-out slip indicates a 31237-nasal debridement was done. There is no need to review the chart or collect for the procedure since post operative care is included in the surgery package.
False: Not every visit after surgery is included in the surgical package. What is included depends on
1. The type of surgery
2. The timing of the post-op visit
3. The reason for the visit
4. The patient's insurance rules
What is a limited benefit plan? Share at least two different scenarios explaining how this may impact a patient at our office.
Patient Impact: Higher out-of-pocket expenses when a plan is limited.
1. Plan covers up to a certain amount for each visit. If they cover $75/visit, the remaining "UA" or allowance is the patient's estimate due.
2. A limited number of visits may be covered annually. Once a patient meets the limitation, they will be charged self-pay rates.
3. Office visits may be covered, but follow-up for allergy testing or a surgical procedure may not be covered if there are benefit exclusions.
A billing alert on file says a Coordination of Benefits (COB) update is due with both plans. Explain to the patient what actions they need to take.
A new patient is insured with Humana Medicaid, and they agree to schedule as self-pay. What important step must the front desk complete at check-in to ensure we are compliant with FL Medicaid guidelines when we bill the patient for the visit?
Front desk must obtain a signed and dated Self-Pay Agreement form from the patient acknowledging that either their primary or secondary insurance is out-of-network, and a claim will not be filed.
The provider ordered a CT scan at the last visit, but prior authorization is denied. Patient is here for a follow-up and wants the scan done at the office today. What solution is available to accommodate the patients request right away?
The patient can proceed as self-pay and receive the CT scan the same day.
*Self-Pay Agreement form selecting option C to opt out of claim submission to health plan should be signed and dated by patient/guardian.