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Dear Director,
I’ve started taking care of the physician-related complaints for my department. How do I decide if and when to adjust a patient’s bill?

Conventional business wisdom says that a satisfied customer will tell five people about their experience while an angry customer will tell 20. This probably holds true in the emergency department, although these days, thanks to social media, that number is probably much higher.

Regardless of how far and wide a dissatisfied patient spreads vitriol on Twitter and Facebook, historically only a small percentage actually lodge formal complaints. These typically fall into one of four categories – the art of medicine (attitude, service or communication), the quality of the medicine (primarily misdiagnosis but difficult for most patients to assess), operations (wait time), and billing.

Excluding the truly small percentage of complaints that come from people who are “crazy,” I find that most complaints contain at least a kernel of truth and a lesson to be learned. Therefore, it’s important to organize and track your complaints. I look at the summary of complaints quarterly and then group them semi-annually for use in the mandatory Joint Commission OPPE that I complete on each provider. Totaling each provider’s complaints and getting a ration of complaints/1000 patients seen can be very eye opening. It’s particularly important to establish a “norm” for your particular environment and patient population, as it can vary from department to department. But  tracking complaints is only part of the process. The real value comes in coaching and educating providers to reduce complaints, improve service, and most importantly, improve the quality of care.

It feels like most patients who complain also want their bill eliminated. Sometimes this is justifiable and other times it’s clearly not. I’ve worked in EDs that felt that eliminating a bill was akin to admitting a mistake, so bills were rarely eliminated. In other EDs, I’ve seen a culture where decreasing bills occurred frequently and was extended as a good faith gesture. While I’m not sure either approach is totally right or wrong, here’s what I look for when deciding how to handle a bill.

The first category is easy: Bills that are clearly wrong. Whether the billing company forgot to contact the insurance company and is charging too much, or is billing for procedures that didn’t occur, these are no-brainer  examples where the bills need to be adjusted. Always apologize to the patient for this coding error and thank them for bringing it to your attention so that you can address these issues with the billing company.

The next category comprises patients who can’t afford the care and are asking for a reduction in the cost. When a complaint comes in six months after the date of service, inability to pay is usually at the heart of the issue. As with any complaint, I review the case to make sure that we did our job correctly. Before I consider dropping the bill, I review the patient’s records and make sure that they are not a frequent ED utilizer and don’t have other outstanding bills. If I believe that the inability to pay is the key issue, I decide if I’m willing to lower the bill, then I give the patient a call. If I’m willing to lower the bill, options include allowing the patient to go on a payment plan or reducing the bill. If I reduce the bill, I clearly relate it to the patient’s difficulty in paying, saying, “I will decrease the bill this time because I can see that paying this bill is very challenging to you,” adding that I want them to be healthy and not fear coming to the ED. I add in that I won’t reduce the bill every time they come to the ED. The last thing you want is a reputation in the community for reducing the bills of anyone who can’t pay. While charitable, it’s not a reputation that will keep you in business. 

The trickiest category is the third: patients who are dissatisfied with their care. . In their mind, getting a bill for an ED visit where they perceived there was a mistake in diagnosis or rudeness from the medical staff adds insult to injury. It’s very important to speak with the patient as quickly as possible after receiving the complaint to pinpoint exactly why they are dissatisfied. While I have waived bills where I felt the doc misdiagnosed the patient – particularly if the patient ended up returning to the ED shortly after the initial visit – I think it’s important to let the patient know that you are adjusting their bill because of their dissatisfaction with the bill, not the dissatisfaction with the care. I don’t relate their satisfaction to the care— after all, the care involves the history, physical, work up, etc…and is not based solely on reaching the final diagnosis. I do agree with a former risk manager I worked with who felt that eliminating a bill because of a misdiagnosis was an admission of guilt and although I’d like to believe in the legal system, I certainly want to protect the defense side when I’m able. In at least some instances, the diagnosis may not have declared itself yet. Consider this: if 1% of your patients return for admission within 72 hours of their initial ED visit, should all of these patients not be billed for their initial visit if they complained, or are many of these admissions a progression of disease or failure of outpatient management? When I talk to this subset of patients I clarify that a lot of care went into their visit, yet I understand their dissatisfaction with the bill. I don’t believe that just because someone complains about a bill, they should receive a decrease in their bill, but I am not opposed to decreasing a bill in many of these cases. What I’ll typically say is, “Your satisfaction is important to us and for that reason we’ve decided to decrease your bill by ___.” Many people will be happy with this while others will want to negotiate. Most are happy that we took their concern seriously and will not only try to prevent their issue from happening to another patient but we are giving them something in return. It’s a case-by-case decision. When negotiating, I do look for a “win-win” solution which includes protecting the ED’s integrity and reputation.

Tracking complaints is a critical administrative measure that will improve care, show outliers among providers, and is necessary for OPPE. A patient complaint does not necessarily mean that a bill should be eliminated. While there are some clear reasons to eliminate a bill, there are other times to either negotiate with patients to maintain their satisfaction with the department and yet still other times where there is no valid reason to eliminate a bill can be found. In this case, tell the patient that their complaint was reviewed, that you appreciate the input but find no reason to adjust their bill for the services received.


Michael Silverman, MD, is a partner at Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center.

 

 

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