1. Monitor and Manage Client Fee Collections
Financial Management Change Package
Best Practice 2
Facilitator Notes
Today we will be discussing the second best practice in the Financial Management Change Package: Monitor and manage patient fee collections.
Activity
Conduct participant and facilitator introductions.
Note to Facilitators
We recognize that Title X grantees have networks of sub-recipients and service sites, and how they’re described can be confusing. For the purposes of this training, we have used agency and site throughout (and interchangeably). We encourage you to refer to your network in the terms you’re most comfortable with/accustomed to using.

2. Financial Management Change Package
Best Practice Recommendations
Bill the correct payer and optimal amount
Monitor and manage client fee collections
Monitor and manage payments from third-party payers (TPPs)
Facilitator Notes
Monitoring and managing client fee collections is the second best practice recommendation outlined in the Financial Management Change Package, which was developed by the Family Planning National Training Center.
The Financial Management Change Package, which is an overview of best practice recommendations and strategies, draws from the literature and most current practice guidelines to improve financial management practices and factors that have an impact on organizational financial health.
The other two best practices in the Financial Management Change Package are:
BP 1: Charge the correct payer and optimal amount.
BP 3: Monitor and manage payments from third-party payers (TPPs)
In order to increase revenue, it’s important to consider all three best practices and utilize a comprehensive approach that addresses each. We strongly encourage you to refer to the Financial Management Change Package for more ideas about strategies and successes. It can be found on the FPNTC website.
Link:

3. Financial Management Change Package: Best Practice 2
Monitor and manage client fee collections
Facilitator Notes
Our topic for today is Best Practice 2: Monitor and manage client fee collections.
This best practice and accompanying strategies we will discuss today focus on client fee collections as a way to improve revenues. This is an important component of agency revenue, and applies to both uninsured/self-pay client fees and to TPP client fees.
An agency may consider implementing a quality improvement (QI) initiative specific to this best practice if:
An agency’s fee collections at time of visit are below national benchmarks (less than 95%)
An agency is not billing for/not billing correctly for TPP associated client fees (or are not sure)
An agency’s client fee balances aged over 120 days is greater than national benchmarks (over 15-25%)

4. Meeting Objectives By the end of today, you should be able to:
Describe the importance of monitoring and managing client fee collections
Describe the challenges related to monitoring and managing client fee collections
Describe at least one strategy to monitoring and managing client fee collections
Describe at least one tool available to manage client fees
Facilitator Notes
There are four objectives for today’s session. By the end of our meeting, you should be able to:
Describe the importance of monitoring and managing client fee collections
Describe the challenges related to monitoring and managing client fee collections
Describe at least one strategy to monitoring and managing client fee collections
Describe at least one tool available to manage client fees

5. Rationale for Monitoring and Managing Client Fee Collections
Collecting client fees is an important component of managing financial health
Uninsured clients
TPP client fees
Facilitator Notes
Client fees include fees for uninsured/self-pay clients (after assessing their family size and income to determine appropriate discount).
They also include fees due for TPP clients— such as copays, deductibles, and/or coinsurances—again, after assessing the appropriate discount.

6. Sub-indicators related to Net Collection Rate
Suggested Performance Indicators to Monitor and Manage Client Fee Collections
Can be broken out by:
Rate for uninsured/self-pay client collections
Rate for TPP client fee collections
Net Collection Rate
Sub-indicators related to Net Collection Rate
For uninsured/self-pay clients
Time of Service Collection Rate
Can be broken out by:
Uninsured/self-pay client fees
TPP client fees
Monthly Client Fees Collected
Facilitator Notes
There are several indicators your agency can use to monitor/manage client fees.
Net collection rate is typically calculated retrospectively. It is calculated by dividing dollars collected by dollars expected for services provided during a specific time period.
This can be calculated for all client fee collections, or subdivided, with one net collection calculation for uninsured clients and a second for measuring collections of fees associated with TPP-covered clients.
Several other indicators related to net collection rate may be easier to measure:
Time of service collection rate: Divide dollars collected from uninsured/self-pay clients by dollars expected for these client services. The best practice is 95%. Your site (or agency) may also choose to collect copays for TPP services at time of visit and then would include these dollar amounts as well.
Monthly client fees collections (dollars collected each month): This can be easily trended and shared with staff. This will not only fluctuate with increased collection rates, but will also fluctuate due to number of clients or due to changes in the number of clients in each discount category.

7. Suggested Performance Indicators to Monitor and Manage Client Fee Collections (cont.)
Percent of fees by aging “buckets”
Can be broken out by:
A/R dollars for uninsured/self-pay clients
A/R dollars for TPP client fees
A/R Aging
Facilitator Notes
Accounts receivable (A/R) aging is another performance indicator used to monitor client fees.
One approach to using this indicator is to identify the percentages in each aging “bucket” (or time bucket) and compare to best practices.
Example: in 121+ day bucket, a best practice is typically less than 15-25% aged claims in this time.
This can be calculated by considering all outstanding dollars owed from clients, or separating those dollars into two different aging categories, one for uninsured/self-pay clients and a second for client fees owed from TPP clients (copays, deductibles, coinsurances).
TPP billing is often completed once the explanation of benefits (EOB) is received. Measuring dollars billed and dollars collected separate from uninsured/self-pay clients enables your site (or agency) to more accurately identify if you have an issue with either or both billing and/or payment processes.

8. Example of Fee Collections Impact
Charges (adjusted) for uninsured/self-pay client services for a month - $4400 Scenario 1: 50 % collection rate—$2200 Scenario 2: 95% collection rate—$4180 A difference of $1,980, or $23,760 annually
Facilitator Notes
To demonstrate the importance of collecting client fees, let’s review this example of an agency’s (adjusted) charges for uninsured/self-pay client services. In one month, these charges totaled $4,400.
In scenario 1, the agency has a 50% collection rate (of fees from clients) that totals $2,200 in one month.
In scenario 2, the agency has a 95% collection rate (of fees from clients) that totals $4,180 in one month.
When we look at the revenue difference between the two scenarios, this equates to nearly $24,000 annually.

9. Discussion of Challenges
What are your agency’s challenges related to monitoring and managing client fee collections?
Discuss
What are your agency’s challenges related to monitoring and managing client fee collections?

10. Discussion of Challenges (cont.)
Changing the culture of the agency
Changing clients’ expectations regarding payment
Balancing customer service and payments expected
Training
Unclear policies and procedures
Facilitator Notes
(Note to facilitators: Skip over any challenges already mentioned by participants or skip this slide altogether, as makes sense.)
There may be a shift in clientele from predominantly uninsured/self-pay to more clients with Medicaid and/or private insurance.
Beginning to collect copays for TPP clients can be a shift in culture for many agencies. Services should be reimbursed at appropriately discounted fees for all clients.
Insurance should be charged for clients with TPP. Copays, coinsurances, and/or deductibles should also be charged (once appropriately discounted) and paid.
Balancing customer service and positive client experience with ensuring payment can be difficult. Uninsured/self-pay clients can become accustomed to receiving services and making little to no payment. Changing their expectations around payment being due at time of services takes consistent, persistent messaging during scheduling, at time of visit, and in written correspondence.
It is important to balance these messages and assure that customer service is not sacrificed and that clients are not denied family planning services for their inability to pay.
Scripting messaging can be helpful.
Training new staff and continuing to train all staff, both front-desk and clinical staff, can be challenging given the day-to-day operations of a busy clinic.
Lastly, it is hard to monitor and manage client fees when an agency’s policies and procedures are unclear.

11. Overview of Strategies for Best Practice 2
Establish and/or update and implement policies on client payment and collection processes
Manage discounted fee collections at time of visit for uninsured/self-pay clients
Accurately discount and bill for TPP client fees
Copays, deductibles, and coinsurances
Facilitator Notes
Now that we have a list of challenges related to fee collection, let’s talk about strategies for improvement.
The first strategy is to establish and/or update and implement policies on client payment and collection processes.
Another strategy is to manage discounted fee collections at time of visit for uninsured/self-pay clients.
Last, but not least, is to accurately discount and bill for TPP client fees, including copays, deductibles, and coinsurances.

12. Strategies for Developing Clear Policies and Procedures
Think about frequency or approach to reviewing and/or developing polices and procedures
Items to address in agency’s policies and procedures:
Scheduling, check in and exit communications
Methods of payment
Time-of-visit payment expectations
Billing/collecting for TPP client fees
Credit balances
Facilitator Notes
It is important to assess the frequency at which your site (or agency) reviews existing policies and its approach to developing them.
Think about how your site (or agency) includes (or does not include) policies and procedures around:
Scheduling, check-in, and exit communications
Methods of payments accepted
Time-of-visit payment expectations
Billing and collecting for TPP client fees
Credit balances
It is important to note that sometimes when collecting TPP fees upfront, an agency may collect more from the client, such as in the copay amount, than they were supposed to. These amounts need to be returned to the client. Each state has its own unclaimed property laws, but the guiding principle is that practices are required to refund any overpayment (in any amount) to clients.
Consider developing scripts for staff, so they can help balance customer service with payment expectations.
Discussion
Does your site’s (or agency’s) policies and procedures address or include these items mentioned? Are your agency’s policies clear? What policies are not clear regarding these items mentioned?

13. Strategies for Developing Clear Policies and Procedures (cont.)
More items to address:
Past due balances
Client communication process
Monthly Invoices
Collection agency (if using)
Payment plans
Client acknowledgment of these financial P&P’s
Training and observing team
Facilitator Notes
Policies and procedures should also address past due balances.
Example: An agency’s policies regarding the use of an external collection agency may include details such as only pursuing those clients with balances over a certain threshold, those who have made no payment for 6 months, etc. Payment plans should outline specifics such as monthly payment amount, how a client can qualify for a plan (such as outstanding balances over $100, etc.), and plans should be agreed upon and signed by the client and your agency. If a client does not honor the agreement, consider expanding your agency’s policy to rely on using a collection agency for procuring the unpaid balance.
It is important to receive client acknowledgement of your agency’s policies and procedures.
One strategy is to provide a client a copy of her/his signed acknowledgement of your agency’s policies and procedures.
While your agency is reviewing and/or developing policies and procedures, it is important to reiterate a Title X requirement that clients not be denied services for their inability to pay.
Often policies and procedures are shared with new employees during orientation. Certain elements may be missed or misinterpreted during this time.
Agencies should review policies and procedures in person and allow for dialogue and questions with staff.
Observe staff members as they perform the job functions outlined in your agency’s policies and procedures and provide feedback. Bad habits can develop, so consider doing so periodically.
When implementing a QI initiative around billing and collecting fees for TPP clients, you may find additional staff training is needed. Routine training is a recommended best practice, regardless of whether you are implementing a specific initiative. Remember your staff, both front-desk staff and clinical staff, play a critical role in billing and collecting fees.

14. Communicate Policies and Procedures to Clients
Clear communication is crucial.
When scheduling, at check-in , and at exit,
Communicate:
Charges/discounts
Payment expectations
Collection policies
Donations
TPP billing of deductibles and co-pays
Facilitator Notes
It is important to communicate your agency’s expectations to clients when scheduling, at check-in. and at exit. Consider communicating the following:
Payment (after assessing for discounts) is expected at time of visit for uninsured/self-pay clients
Payment methods your agency accepts (accepting check, cash, credit or debit card as methods of payment is a best practice)
Insured clients should bring their insurance information. Explain that there may be fees for balances not paid by TPP (copay, deductibles, coinsurance). Also explain your site’s (or agency’s) policies regarding collecting client-owed balances after a TPP has paid.

15. Words Make a Difference
“How will you be paying for your services today?”
versus
“How much can you pay for services today?”
Facilitator Notes
Consider developing scripts for your front-desk and exit staff.
Note the difference in wording between these two statements.
Discussion
How does your site (or agency) ask clients for payment? What is the current practice(s)? Give two examples.
Which might be more effective and why?
Facilitator Notes for Discussion
The first is a more open (effective) way to communicate with your clients.

16. Strategies for Managing Fee Collections at Time of Visit
For uninsured/self-pay clients:
Collect fees for services provided at time of visit
Best chance of collecting is at time of visit
Accept cash, check, credit and debit cards
For all clients:
Monthly invoice process
Identify/communicate balances during the scheduling process
Facilitator Notes
Managing fee collections at time of visit is critical.
Uninsured/self-pay clients:
Collecting discounted fees for services at time of visit is your agency’s best chance of collecting client fees.
When uninsured/self-pay clients call to schedule their next appointments, remind them of your agency’s policies around collecting (appropriately discounted) fees at time of visit and share the methods of acceptable payment such as cash, check, and/or credit and debit cards.
All clients:
Develop and/or maintain an up-to-date monthly invoice process for all clients with balances. Your site (or agency) can send statements every 30 days. Consider using a collection agency and/or establish specific policies and procedures for payment plans.
Identify past due balances when clients schedule new appointments.
Train front-desk staff to:
A recommended practice to improve client fee collections is also to communicate past due balances to all clients and that payment is expected at the next appointment.

17. Strategies for Billing & Collecting Fees
From TPP clients
Bill/collect post-TPP adjudication
Title X regulations regarding the discount to the remaining balance
Calculating appropriate discount
Utilize past due balance tactics previously outlined
Facilitator Notes
Let’s go into more detail on collecting fees from TPP clients.
Once an explanation of benefits (EOB) is received, your agency will know the exact amount the client with TPP is responsible for such as copays, deductibles, and coinsurances.
Collecting client fees prior to receiving the EOB is allowable, but it can lead to credit balances and create additional work for your billing staff to process them.
It is critical to remember Title X guidance—that clients should never pay more than what they would owe based on the sliding fee scale.
Remember, all clients, regardless of insurance status, require a family size and income assessment when they present for services (not just uninsured clients). Use this information as well as Title X guidance to assure an accurate discount calculation of the copay/deductible fees.
It is also recommended that sites (or agencies) utilize past due balance tactics as needed. These include:
Communicating to clients your agency’s policies, what clients owe, etc.
Sending regular past due statements to clients
Utilize a collection agency, if your agency does and it is outlined in the policies and procedures
Implement client payment plans

18. Copay Example
Full charge for service is $125. Your agency has a contractual agreement with ABC insurance to discount the charge to $100 and to charge the client a $25 copay.
Client A is eligible for a 90% discount based on sliding fee discount schedule
How much should client pay?
Client B is eligible for a 50% discount based on sliding fee discount schedule
Facilitator Notes
Let’s talk through an example of how an agency would apply Title X Requirements and meet contractual obligations with a third-party payer
Discuss
In this example, let’s say your full charge for a service is $125. Your agency has a contractual agreement with ABC insurance to discount the charge to $100 and to charge a client a $25 copay.
Client A is eligible for a 90% discount based on your agency’s sliding fee discount schedule. How much should this client pay?
Client B is eligible for a 50% discount based on your agency’s sliding fee discount schedule. How much should this client pay?
Facilitator Notes for Discussion
Client A: ABC insurance is obligated to pay $100 minus the copay ($25).
ABC insurance pays $75.
The client pays $12.50.
To accurately calculate what a client with TPP owes, first calculate the fees as if the client is uninsured/self-pay. Slide 90% of the full charge ($125). This slid amount is $ Now compare the slid amount to the copay amount ($25).
Which amount is lower? The slid amount ($12.50).
This is what the client with TPP pays as per Title X guidance, a client with insurance should not pay more than what they would if they were paying on the sliding fee discount schedule. (See Section of the Program Requirements for Title X Funded Family Planning Projects,
What about the rest of the charges?
$25 is written off as a contractual adjustment—this was money you weren’t ever going to collect with ABC insurance.
The remainder of the copay ($12.50) is written off as bad debt. Title X funds help to offset these amounts.
Client B: Similar to Client A, ABC insurance is obligated to pay $100 minus the copay ($25).
ABC insurance pays you $75.
To accurately calculate what a client with TPP owes, first calculate the fees as if the client is uninsured/self-pay. Slide 50% of the full charge ($125). This slid amount is $ Now compare the slid amount to the copay amount.
Which amount is lower? The copay amount ($25).

19. Deductible and Copay Example
Same scenarios, but Client B has not met the deductible.
Full charge for service is $125. Your agency has a contractual agreement with ABC insurance to discount the charge to $100 and to charge the client a $25 copay.
Client B is eligible for a 50% discount based on sliding fee discount schedule
How much should client pay, accounting for the deductible?
Facilitator Notes
Now let’s complicate things with a deductible. It is the same scenario, but client B has not met the deductible.
Discuss
Your full charge for a service is $125 and your agency has a contractual agreement with ABC insurance to discount the charge to $100 and to charge a client a $25 copay.
Client B is eligible for a 50% discount based on your agency’s slide fee discount schedule. Client B has not met the deductible. How much should the client pay, accounting for the deductible?
Facilitator Notes for Discussion
Answer: $62.50
Your full charge for the service is $125, based on your agency’s full fee schedule. The reimbursement amount under your contract with ABC insurance was $100, minus a $25 copay.
To accurately calculate what a client with TPP owes, first calculate the fees as if the client is uninsured/self-pay.
Slide 50% of the full charge ($125). This slid amount is $ This is the maximum amount a client can pay in this situation.
If deductible is not met, Client B should be billed or pay at time of visit $25 for the copay and an additional $37.50 (for a total of $62.50). This amount is 50% of the full charge.
Now let’s talk about what is applied to the deductible and what to do with the balance. ABC insurance company has applied $75 to the client’s deductible. Copay amounts ($25 in this example) are not applied to the client’s deductible.
The difference between the contractual agreement amount ($100) and the amount you collected ($62.50) is $37.50.
This is the bad debt write-off adjustment that you make on this account. Title X funds are intended in part to help cover these write-offs. The difference between the $100 and the $125 is again a $25 contractual adjustment write-off. It is differentiated from the bad debt write-off, as you were not expecting to receive these dollars.

20. Fee Collection Tools Client Fees Calculator Facilitator Notes
The Family Planning National Training Center developed a few tools to support Title X agencies in calculating client fees. One tool, a Client Fees Calculator, can be used to collect client fees accurately. As users update the full charge and client discount columns, the remaining columns will adjust. Users will also need to update insurance contracted amounts, as these amounts may differ by insurer (i.e., Aetna versus United).

21. Fee Collection Tools (cont.)
Title X Client Fee Collections Frequently Asked Questions
Facilitator Notes
Another resource the Family Planning National Training Center has developed is a Title X client fee collections “frequently asked questions” (FAQ) document. The FAQ addresses common issues within the Title X network.

22. Case Scenario What do you do?
You begin to monitor TPP client billing of copays and deductibles. While observing billing procedures, you note that amounts are being discounted incorrectly, and that only one invoice is sent out. The resulting A/R of these accounts is that 72% of balances are outstanding past 120 days.
What do you do?
Facilitator Notes
Let’s work through a scenario together.
Discuss
What do you do?
What is a small change you can make, and how can you measure improvement?
Facilitator Notes for Discussion Question
Possible answers include:
Train staff to use the client fees calculator
Train staff to identify past balances due and to tell clients when they call to schedule appointments
Train staff to identify past balances due at check-in and/or exit, and to communicate at these times as well
Develop scripts for staff members to assist with balancing fee collection practices with customer service
Implement monthly invoicing process for at least 3-4 months
Consider payment plans and/or use of a collection agency

23. Success Story
Southern Nevada Health District, a Title X grantee with two service sites, wanted to improve its overall fee collection rate of both time-of-visit services and past due balances. They also wanted to improve client income information gathering to calculate discounts and correct fees accurately.
Actions taken
Simplified financial intake form; added specific financial questions
Trained staff to identify past due balances for clients when calling for a new appointment
Trained staff to communicate to all clients what payment was due when scheduling an appointment and also at time of visit
Facilitator Notes
Now let’s look at a success story from the field. We know it can be valuable to see how are other Title X sites are implementing these best practice recommendations.

24. Success Story (cont.) Results: Key points:
Increased collections per uninsured client from an average of $8.31 to $25.35 over a four-month period, resulting in an increase of nearly $8,000 in monthly fees collected
Key points:
Developing a script for front desk staff and observing staff using it was helpful (past due balances, payment due at time of service, payment methods, etc.)
Measuring and sharing results/improvements each month was motivating
Consistent, persistent client communications during scheduling, check- in, and exit were helpful in changing client expectations
Discuss (if time allows)
What is one strategy from this success story that you could implement in your setting?

25. What other questions do you have
What other questions do you have? What other issues would you like to discuss?
Discuss (if time allows)
What other questions do you have for each other before we end? Are there other issues or challenges that we haven’t discussed yet? (Note to facilitators: If challenges came up in earlier discussions, this could be a good time to discuss them.)
Before we leave, what is one thing you will take away from today’s discussion? (Note to facilitators: Consider round robin sharing or ask a couple of participants to share.)

26. Contact: fpntc@jsi.com
Thank you!
Contact:
Facilitator Notes
Thank you for participating in today’s discussion!
If applicable, you can contact me at:_________
You can also always contact the Family Planning National Training Center with questions/comments.