Guide Detail | AskDCH

Purpose

The purpose of this guide is to give Patient Access and Financial Clearance staff consistent scripting when discussing estimated patient responsibility. Using consistent scripting helps staff communicate clearly, reduce confusion, explain insurance responsibility in a patient-friendly way, and support point-of-service collection efforts while keeping the patient’s care and experience first.

Situation / Scenario

Use this guide when discussing a patient’s estimated responsibility at the time of service. This includes conversations about copays, coinsurance, deductibles, estimated out-of-pocket responsibility, partial payments, payment plans, and patient questions or concerns about why payment is being requested upfront.

Step-by-Step Instructions

Before speaking with the patient, make sure you have verified the following:

Insurance benefits have been checked
Estimated patient responsibility has been calculated
Copay, coinsurance, deductible, and out-of-pocket information have been reviewed
Payment options are available if the patient cannot pay the full amount
Staff are prepared to explain that the amount is an estimate based on verified benefits

Helpful Tips

Always explain that the amount is an estimated responsibility based on verified insurance benefits.
Keep the conversation calm, clear, and respectful.
Ask how the patient would like to pay instead of asking if they want to pay.
Offer partial payment when the patient cannot pay the full amount.
Offer payment plan options when appropriate.
Remind patients that insurance benefits are determined by their insurance plan.
Avoid arguing with the patient about what they believe insurance should pay.

Common Mistakes

Do not argue with the patient.
Do not tell the patient they must pay in full before receiving care unless that is part of a specific approved process.
Do not promise that insurance will pay the remaining balance.
Do not tell the patient the amount is guaranteed.
Do not dismiss the patient’s concerns.
Do not say, “That is just what you owe,” without explaining that it is based on their insurance benefits.

What NOT To Do

Saying the amount is final instead of estimated
Asking, “Do you want to pay today?” instead of “How would you like to pay today?”
Not offering a partial payment option
Not offering a payment plan option when appropriate
Blaming the patient or the insurance company
Making statements outside of verified benefit information
Telling the patient insurance will pay a specific amount if that has not been confirmed

Escalation Instructions

If the patient has additional questions or concerns that staff are unable to resolve, follow the department escalation process.

Possible escalation needs may include:

Patient disputes the amount
Patient requests additional billing explanation
Patient becomes upset or refuses to continue the conversation
Benefit information appears incorrect
Staff are unsure whether payment should be requested
Patient requests financial assistance information