Knowledge Center

Transition from Patient Billing To Guarantor Billing

Nick McLaughlin,
Ridiculously Nice Sales and Business Development

Most healthcare billing systems are great at combining bills from different encounters on a patient or account basis. However, a higher level of customer service can be achieved with guarantor, or household billing.

Allow me to set the scene. Greg and Stacy have three children and the whole family is under Greg’s employer’s health plan. Greg will be the guarantor no matter which child is the patient. In most billing systems, if Stacy brings a child in for an office visit, Greg has a knee replacement, and another child has to visit the Emergency Department, Greg would receive a separate bill for each patient, with none of them reflecting Greg’s total balance with ABC Healthcare. In our experience at Americollect, guarantors like Greg would much prefer to have one, guarantor-level statement with ABC Healthcare. Meaning each statement would include self-pay balances for all members he is the guarantor for in the household. Not only does aggregating the accounts under one guarantor improve the patient experience with billing statements, it improves the patient experience working with your Patient Financial Services Department. Greg no longer needs to bring up each account number with your Customer Service Representative, one-by-one, and add them up to get a total balance.

How To – Guarantor Number Creation

For starters, defining terminology is the first step to take when discussing guarantor billing. Below are common healthcare system terms:

  • Medical Record Number – unique set of digits associated with the patient
  • Guarantor Number – unique set of digits associated with the guarantor
  • Account Number – unique set of digits associated with the date of service

The system you use today may already be using this type of combination. If not, we may be able to help you improve the patient experience through guarantor billing.

The guarantor number in this case is critical to successfully executing this flow. However, at Americollect we understand some healthcare information systems are more challenging to use, and may need more attention to develop. Americollect has designed programming to take common data elements such as name, DOB, and address to assign guarantors and created custom programming to manage, organize, and create a guarantor-based statement. The guarantor then receives a statement once per month on all balances currently in self-pay. If an account is paid in full, we manage their statement cycle, and as the guarantor balance increases with successive services, we work with our clients to customize the best statement workflow for them. Greg and his children will be on one statement. Greg’s wife, since she is her own guarantor, would be on her own. Some organizations manage their guarantors by whomever brings the child in, and not whomever holds the insurance policy. We have seen that process work just as well. Greg receives his proper statements for all his self-pay responsibility and Stacy receives hers.

Result – Improved Patient Experience

The best part is that we have integrated our phone systems and calling workflows to ensure Greg or Stacy have received at least one statement reflecting their current total balance before calling their accounts. We always want to discuss their total guarantor account balance, and create a full-scope conversation to shape the patient experience from the back-end to the front-end. This saves your customers and your team time on the phone discussing multiple accounts at different times, and time is money!



Emergency Room for Non-Emergent Problem

Shawn Gretz, 
Ridiculously Nice Vice President of Sales

Blue Cross and Blue Shield (BCBS) is no longer paying for the boy who cried wolf in four states. You know the old wives’ tale – A bored boy tending sheep cried “Wolf!” to get attention. He did it a second time, and again the village people came to help him. The third time the boy cried “Wolf!” and the boy was ignored but this time the wolf was real and his flock of sheep was eaten. The moral of the story… BCBS doesn’t want patients utilizing the emergency room when a primary care doctor will do!

BCBS in New York, Georgia, Kentucky, and Missouri will be no longer paying for non-emergent use of emergency departments. It is an interesting stick that BCBS is using to try to drive the patient to cheaper options for healthcare.

What does that mean for Americollect clients? I am afraid to say that it is going to mean more bad debts and confusion for patients if you work in those four states. I also feel that this provision is one that could potentially spread to other insurance companies and divisions of BCBS before long.

What can you do? I believe now is the time to start training all registration staff in the emergency department to have the discussion with patients that have non-emergent problems as they leave the ED. Educate them on the options they have for service that would be in their best interest, or they risk paying the charges themselves if the service isn’t covered in the future.

TCPA Language – Are your contracts updated?

Joelle Mark, 
Ridiculously Nice Compliance Officer

The Telephone Consumer Protection Act puts restrictions on how we are able to contact consumers to collect on your accounts.  Some general provisions of the TCPA include but are not limited to; prohibiting calls made to a cell phone with an automatic dialing system without prior express consent and prohibiting faxing, e-mailing and texting unsolicited advertisement without prior express consent.

The TCPA not only affects Americollect, but you as medical providers if you are using an automatic dialing system for appointment reminders, notifications of prescriptions, or anything else.  There are a few ways that you can help protect both your collection agency, as well as yourself, from litigation under the TCPA.  Do not skip trace for phone numbers. Make sure that if a phone number is for “next of kin”, it is labeled correctly, document that the phone number was given to you by the patient or guarantor, and update your admission agreements, online login agreements, and yearly HIPAA sign offs with the following language:

You agree to receive pre-recorded/ artificial voice messages calls and/or use of an automatic dialing device, text messages and/or emails from CLIENT NAME, our partners, subcontractors, or any and all other companies that we may have to transfer your account to at any telephone number or email address that you have provided us or that we have otherwise obtained, which could result in charges to you.  We may place such calls, texts or emails to (i) notify you regarding upcoming appointments; (ii) notify you of results; (iii) troubleshoot problems with your account (iv) resolve a dispute; (v) collect a debt ; or (vI) as otherwise necessary to service your account or enforce this admissions agreement, our policies, applicable law, or any other agreement we may have with you.

 The ways in which you may provide us a telephone number or email address include, but are not limited to, providing the information at account opening, adding the information to your account at a later time, providing it to one of our employees, providing it to our partners, subcontractors, or any and all other companies that we may have to transfer your account to, or by contacting us or our partners, subcontractors, or any and all other companies that we may have to transfer your account to from that phone number or email address. If a telephone number provided to us is a mobile telephone number, you consent to receive SMS or text messages at that number. Standard telephone minute and text charges may apply if we contact you. You may revoke this express consent at any time by calling us at: XXX-XXX-XXXX.

By adding the above language to your admissions agreements, you are taking huge steps help Americollect remain compliant with the TCPA which means an ability to collect more money on your accounts.

For questions, please contact our Compliance Team at 800-838-0100 or



“Why Are Medical Bills So Confusing?”

Shawn Gretz,
Ridiculously Nice Vice President of Sales

This is a question that the US Department of Health and Human Services (HHS) decided to tackle when they released a design contest titled “A Bill You Can Understand.” To view the report and winners visit: The report from the study does a great job of describing the problems patients have with the largest post-service touchpoint, the medical bill. The contest had two prizes: 1. Easiest Bill to Understand, and 2. Process -Transformational Approach to Medical Billing. This article is a synopsis of the problem areas the report found, along with solutions that the contest winners brought forth that we believe have true potential. We will also address what you can do right now to provide “a better patient experience.” (Besides hiring the Ridiculously Nice Early Out and Collection agency if you haven’t already!)

Problem-“Complexity Kills the Payment”

The first problem identified in the report was the complexity of charging for healthcare services. Issues raised in the report include:

  1. Patients are confused by the fragmented care provided by multiple doctors and facilities who all bill independently;
  2. Patients rarely know what they are going to have to pay before a procedure;
  3. Patients do not know where to turn for answers to their billing questions; and
  4. Patients do not understand the denial, appeal, and insurance resubmitting process.

Let me also include that studies show (including one done by that on average patients do not understand deductibles, co-insurance, co-pays, and out-of-pocket maximums.

Problem-“Volume of Communications”

Consider from a patient perspective all the written and verbal communications that a patient receives from one visit. The complexity is mind-boggling to the point that it creates a barrier to payment. The communications include:

  1. Pre-Service – Price comparison, registration, pre-authorization, and appointment reminder – Oh my! Each one of these touch-points have a potential for patient dis-satisfaction. The biggest medical service that has removed the complexity is the one we would prefer to steer patients away from, emergency care. There, a patient can skip this step and just come on in.
  2. Appointment – At the appointment, the volume of communication continues. At the registration desk the annual HIPAA authorization, pre-service paperwork including authorization to bill along with Telephone Consumer Protection Act express consent. Then there is the verbal nurse’s instructions, verbal doctor’s instructions, pamphlets, prescriptions, and written instructions for after service.
  3. Billing – Even after the service, the volume of communication continues.
    1. Explanation of Benefits (EOB) – First come the EOBs with their confusing language of deductible and co-insurance. Add in the coding for the procedures and doctor names that the patient doesn’t even recognize for service. Multiply this by the multiple EOBs for facility, ER, anesthesiology, radiology, or pathology bills.
    2. Statements – Next comes the patient statements that may be come 30-45 days later and not just from the facility but again from ED physicians, anesthesiology, radiology, and pathology. Each of these statements may or may not match the EOB. Let’s take the patient paperless. Great now you need multiple logins from each of the different services to pay for the service. Most emails that I have seen sent to patients do a poor job of describing the services because of HIPAA’s requirements to send a clear communication of who the patient was and what the services were for.
    3. Verbal – Next come the communications with a call center that hopefully is staffed correctly to handle the incoming volume.

    Each and every one of these communications leaves space for the patient to be dissatisfied or choose to seek services somewhere else. Combine with this that the article points out that patient understanding, terminology, timing, and trust plays a role in patient payments.

    Solutions Offered:

    1. Patient Journey Mapping – A solution can only be solved when you state the full problem. In this contest one of the requirements was to create a patient journey map of all the touch points from the patient revenue cycle, and qualify them as either producing a positive or negative experience; thereby stating the problem. I would suggest you try this process yourself. Bring together your team to follow a patient’s journey through the experience you are creating for the patient. Search for those positive and negative touch points and remove the negative when possible.
    1. Deductible and Out-of-Pocket Maximium – The organization RadNet revealed a statement design that included a pie chart with the deductible and out-of-pocket maximum information. Patients who receive a statement such as this may stop looking at the EOB, and wait for your statements to make it less confusing. This information would be available through most clearing houses at the time the statement is generated.
    1. Doctors – Another design change by RadNet was to show images of the doctors next to each itemized charge. This refreshes the memory of the patient making it easier for payment. Along with the images is a QR code that could quickly take the patient to a FAQ spot to describe the service or facility being charged for to explain away the complexity.
    1. All Physicians – A submission by St. Luke’s in Boise, ID brought together all physicians, regardless if they operate independently, onto the statement sent to the patient. Imagine if you could differentiate yourself by making it easier for the patient to pay by sending one statement for the entire service. Many groups and their billing companies struggle to find a way to continue to collect self-pay balances. By combining these charges with your self-pay charges, significant cost savings could occur from statements and phone calls for the physicians.
    1. Terminology – The simplest way to generate a statement is to use the already provided terminology on the charge master. This may also be adding unneeded complexity to the bill. Consider providing the statement company a different table to simplify the language of the charge master into what the patient can understand. Also consider viewing the EOB from time to time of patients to see if the insurance companies terminology matches your terminology.

    These five solutions can all create a better patient experience as does choosing the right partner to implement these. I suggest you look to implement these in the future or journey map your own solutions to the complexity.

    Americollect is looking for partners to build a “Patient Journey Mapping” case study with, including providing early out services for a hospital or health system and their contracted physician groups. The overarching goal being to improve your patient experience.  Let Americollect come on site with our team to map out the current patient experience and redefine the future with you. If you would like to explore this opportunity with us, reach out to Shawn at or 920-420-3420.

Reconsider Having your Collection Agency Send your 501r Final Notice

Shawn Gretz,
Ridiculously Nice Vice President of Sales

Over the past three years, I have had many conversations with not-for-profit hospital clients and potential clients who have asked Americollect to mail the 501r extraordinary collection action final notice on their behalf. Each and every time, I have steered them away from Americollect mailing this letter on their behalf due to liability concerns. Just last year, a court case gave me my “I’m so glad we didn’t do that!” moment for why a collection agency should not send this on your behalf.

Before we dive into the court case, here is a little background on two regulations:
501r: This regulation, governed by the IRS and part of the Affordable Care Act, requires not-for-profit hospitals to provide “financial assistance” to patients. The regulations spell out certain requirements to meet the IRS guidelines. More information on 501r can be viewed at:   One of the guidelines is, if a hospital chooses to do extraordinary collection actions (ECA), which is defined as credit bureau reporting, legal, or judicial actions against a patient, then the hospital has to mail a written (final) notice to give the patient a deadline after which the intended ECAs may be initiated. That deadline must be no earlier than 30 days after the date that the final notice is provided.

In addition, the regulations require the final notice to generally indicate that financial assistance is available for eligible individuals. Also, the final notice must list the intended ECAs the hospital facility may use.
FDCPA: The Fair Debt Collection Practices Act (FDCPA) is a regulation that collection agencies must follow. The FDCPA prohibits collection agencies from using “false, deceptive, or misleading representation[s] or means in connection with the collection of any debt.”

So how did these two regulations intertwine together for a court case? In 2016, Nina Flecha filed a class action suit under the FDCPA alleging that a collection agency (that will go unnamed and is NOT Americollect) mailed a final notice with a false threat to sue. Mrs. Flecha’s case is that Seton Medical Center does not allow legal action as part of their ECAs. The unnamed collection agency should have simply updated their final notice, removing legal action from the list of ECAs, and they likely would not have this class action suit filed against them. I believe that in the future there will be more cases in regards to another part of the FDCPA.

Part of the FDCPA says that collection agency communications have to take into account the “least sophisticated consumer.” This standard sets the bar for which communications can occur with patients. Consumer attorneys often sue collection agencies for language that could be confused by the “least sophisticated consumer,” and by having your collection agency mail your final notice. In a future newsletter article, we will address the “least sophisticated consumer” and why understanding this language is important to collecting; whether you are the hospital or a collection agency.

Oh by the way, this still doesn’t address the 501r requirement that, “the final notice must generally indicate that financial assistance is available for eligible individuals.” The conspicuous written notice requirements include that a “direct phone number and website address where applications, policies, and plain language summary” must be included. This is another place where a “least sophisticated consumer” could become confused.

Please, for the sake of your organization, don’t have the collection agency send your final notice as you never want the hospital’s name involved in a court case that could be avoided!

Reporting Pay Directs – Get it Right the First Time

Joelle Mark, Ridiculously Nice Compliance Officer

Americollect is working hard to change the way collection agencies are viewed, in a positive way!  We do this by being Ridiculously Nice and by partnering with our clients to make sure your accounts are accurate.

After an account is listed for bad debt, a patient may send the money directly to you, the medical provider.  If Americollect doesn’t know about the payment, we make calls and send letters to your patient. This may lead to the patient(s) becoming upset or confused and patient satisfaction scores may drop, file a complaint or even a lawsuit due to the collection agency attempting to collect a debt that is paid.  This is not only bad news for the collection agency, but, due to vicarious liability, it could also lead to a complaint or a lawsuit against the medical provider.

We want to do everything we can to ensure we have accurate information in our office as well as keeping our clients safe from complaints.  One of the steps we take to ensure accurate information is partnering with our clients to make it easier for them, too.  Here are some ways that Americollect can help:

Client Connect

  • Americollect offers an online portal for our clients to list, update and follow up on patient accounts. Our Ridiculously Nice Client Relations Department offers a detailed training session when access is requested for Client Connect.

System Access

  • By having access to our clients’ systems, we can do all of the work and make sure payments are reported correctly and timely. This also minimizes the need for us to call or email you for information.

Automated Payment and Adjustment Files

  • Most of our clients have electronic data files that are sent to us daily to automatically report and post any direct payments or adjustments made towards accounts. Please contact to get this started!

Reconciliation Files

  • Many of our clients send us a reconciliation file weekly or monthly. A reconciliation file is similar to an automated payment and adjustment file, but instead of just focusing on payments and adjustments, it focuses on making sure what we have listed in our office matches what is listed in our client’s office in every aspect.

If any of the above options are something that you have thought about, but did not know where to get started, give us a call and speak with our Ridiculously Nice Implementation Team. They will be able to help you decide which option would work best for you.

What data would be in an ideal payment and adjustment file: Your patient account number or visit number, the date it was listed for collection, the amount of the payment or adjustment, the date it was posted to your system and your balance after the payment or adjustment was posted.  The last item is wonderful to have on an “on-the-fly” reconciliation process.

In the year of 2017, we will be reaching out to our clients who do not have a systematic way to report payments and adjustment to develop a recurring process.  Let us help you improve patient satisfaction scores and prevent potential complaints and lawsuits. Please contact to get this started!


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A Healthy Serving of Patient Experience

Nick McLaughlin, Ridiculously Nice Sales

Not less than ten years ago we had to train our collectors for the common complaint from the patient of, “My insurance is supposed to pay 100%”, but for most American’s those days are long gone. The more likely complaint is now, “How am I going to come up with the $5,000 deductible.” This article is going to dig into the expected “patient experience” as a healthy serving of self-pay has been served up to you by insurance companies. Patients who have never dealt with a health system have an expectation that credit cards, cell phone, cable, utilities and other consumer service centers have created. Will you live up to the expectations and create a “better patient experience”?


There are more opportunities to screw up the best way to do statements than earn praise for doing a good job. If your statements follow the recommendations of HFMA’s Patient Friendly Billing Initiative, and you send the three monthly statements that 501r requires, you are on the right track. But before we move on from the subject of statements, let us begin the war on over-statementing. Did I just make up a word? Maybe! But you know what I mean. Occasionally, we still run into hospitals that send 5 or 6 statements to each patient before the account goes collections. This is a completely unnecessary waste of money. Almost as bad as that is when a hospital that has just converted to a new system sends their patients one statement for their accounts in the old system, and a separate statement for their accounts in the new system, and the new statement doesn’t include the accounts that are still due in the old system!

Imagine if your credit card company upgraded their system and began sending you two different bills, one for your charges before February 1, when they converted, and one for your charges after February 1… Their customers would be up in arms! The moral of the story is: combine your systems. Patients are screaming for one experience whether they visit your doctor’s office, hospital, or ambulatory surgery center. If your name is on the door, then one consolidated patient friendly statement and payment plan should be established for the patient. We specialize in combining multiple entities and systems into a better patient experience. It will help your patients lower their blood pressure, save you money, and prevent your patients from getting so frustrated they go to your competitor down the street.

Ridiculously Nice Calls

Making timely, friendly (we call Ridiculously Nice) follow up calls, and making them efficiently, is where a huge opportunity to improve the patient experience and cash flow lies.

We recommend starting outbound phone calls to patients 35 days after the initial statement is sent. We have found that calling patients before the first month is up, even in a Ridiculously Nice manner, creates awkward conversations, because patients expect to be given until their due date to pay the bill (normally a month later). Another great reason to start calling at day 35 is because the patient likely received their second statement 2-3 days ago, so it should be relatively fresh in their memory.

After the initial call, we recommend calling every 8 days, excluding weekends, until you get in touch with the patient. The 8 day interval causes you to call on a different day of the week each time, increasing the likelihood of a connection. Once the patient is reached, let the Customer Service Representative decide what the next best action is based on their conversation with the patient (payment-in-full, payment arrangement, try back next Friday because that’s payday, etc.)

I’ve heard some hospitals express concern that their staff might not be treating patients as well as they should on the phone. Call quality assurance is extremely important, which is why we use and recommend a tool called CallMiner. CallMiner monitors every single call for elevated tone, abusive language, right party contact, and many other helpful metrics. It alerts a supervisor if an issue comes up, allowing leadership to help right the situation.

Remember before when we discussed being compared to credit cards, cell phone, cable, and utilities? These markets have experience providing great customer service to keep customer satisfied. Two of the main metric they track in their call center are abandonment rates and/or average time to answer. These two metrics will tell you if your customer service team is providing a better patient experience. Abandonment rate should be under 5% and average time to answer should be under 20 seconds. If you are not meeting these marks, then it is time to ask yourself if you are frustrating your patients.

Payment Plans

Many hospitals leave money on the table by setting up a payment plan with a patient, and then never touching it again, even if it becomes delinquent. There are two very helpful times to reach out to a patient on a payment plan: when that patient has a new balance added to their total, and when that patient misses a payment or pays less than agreed. We set up programming that monitors all payment arrangements in our care, and queues a phone call to either increase the payment plan when a new balance comes in, or catch up on the payment plan if a payment is missed or underpaid.


We have seen phenomenal improvements in the efficiency and effectiveness of our Early Out/Self Pay service by implementing these best practices: statement consolidation, follow up calls every 8 days starting at day 35, CallMiner for call quality assurance, and calling patients when they miss/underpay a payment plan or a new balance is added to their total. We hope you can capitalize on what we’ve learned by either implementing these practices in your billing office, or calling us to see if we can help you in that area!

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501r Help is Here!

Shawn Gretz, Ridiculously Nice Vice President of Sales

I hate doing my taxes. First, there is the waiting to receive my W-2, 1099, 1095, and 10-4. The last one isn’t real, but you know what I mean. Then there is the gathering all the taxes documents together and either calling a CPA and waiting a month for an appointment or working with TurboTax to complete your taxes by yourself. The entire process is time-consuming and tedious. The same can be said about 501r. The connection here is that IRS is behind both pains. Well, if you are experiencing pain with 501r, Americollect is here to help.

If you have found the IRS “oral notification” or “final notice” process tedious or time-consuming for your staff to complete, then let Americollect use our dialing technology and relationship with statement provider to send them on your behalf. Here is the painless process:

  1. Transfer File: Transfer a simple file with the patient demographic information to Americollect with all account balances ready for an oral notification or final notice.
  2. There is no two. The rest we will handle.

This takes a 30-minute setup call with Americollect to ask a few simple questions such as:

  1. What number should patients be sent to if they have questions about financial assistance?
  2. What “Extraordinary Collection Actions” do you perform?
  3. Can I have a copy of your plain language summary?
  4. Can you email me a copy of your logo?

For more information about how Americollect can make 501r “oral notification” or “final notice” painless call Shawn at 920-420-3420 or email For any other questions about 501r, please call or email Shawn above or visit our website at

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To view our recorded webinars on 501r, click here.

Reference Based BULLY-ing

Shawn Gretz, Ridiculously Nice Vice President of Sales

A letter or EOB arrives at your facility from the bully that states: Accepting and depositing the previously sent payment means the Provider “agreed that such payment constitutes an accord and satisfaction and will take precedence over any previous terms,” or “we demand that the hospital cease and desist all collection activity against the beneficiary and demand that the hospital appeals the determination through the Plan’s internal dispute resolution process.”

As any person being bullied knows, and as Freud has written, there are two options: 1. Fight or 2. Flight.

Background: Since the 1980’s, the basic approach employers have used to control healthcare costs has been through Preferred Provider Organizations (PPO) that negotiate discounts off the gross/billed charges. This is considered “top down” negotiating. “Top down” negotiating leaves room for a hospital to overstate the gross costs for a procedure leaving the insurance company paying a lot more than the actual cost of a procedure. Enter in self-funded groups who want to work the way Medicare does with “bottom up” pricing as a means to control costs. Medicare establishes a base rate for each service and then makes adjustments based upon patient complications, geographic location differences, and other factors to determine the maximum amount they will pay a hospital for a procedure.

Self-funded/employer-sponsored health plans would prefer to work the way Medicare does by using “bottom up” pricing or what is termed Reference Based Billing. They are electing not to enter into a contract with hospitals and have no provider network or one that is very limited. A patient is free to choose any hospital they wish to have the procedure done, which patients appreciate versus being told which facility they must visit because it is in-network. These plans want to limit the payment for the hospital services provided to the patient by “Re-Pricing” the service at a “bottom-up” amount. Many benefit consulting firms are telling these health plans that they can state their “bottom-up” price. They create what is called an “allowable claim limit.” “Allowable claim limits” for inpatient are based upon a percentage of Medicare reimbursement or cost as reported to Medicare on the most recent cost report.  Generally, this is 120%-150% of Medicare costs or other published data. Some reference based pricing models are only doing this for specific procedures such as appendectomy or knee-replacements.

After the service was provided to the patient, a hospital usually receives payment on an EOB stating that by depositing this payment the hospital is agreeing to accept the “bottom-up” pricing and the amount should be considered payment-in-full minus any co-payments, co-insurance, or deductibles that the patient may owe. The idea is that reference based bullies want you to think that you cannot balance bill the patient. This is the “flight” that these self-funded/employer sponsored health plans are hoping you choose.

But Can You “Fight” or Balance Bill the Patient?

The answer is usually YES, but be ready to deal with legal counsel from the self-funded/employer sponsored group to start the bullying. Before we get into how you can defend your “fight” or balance billing the patient, let’s talk about the offense and defense to fight this bullying. As any sports fan has heard “the best offense is a great defense.”

 Defense Tactic #1: Admissions and Registration need to be on the lookout for insurance cards that read:

“We restrict hospital charges to the amount the Plan deems reasonable and states that by accepting an assignment of benefits from the beneficiary, a hospital waives any right to recover payment more than the Plan determined Allowable Claim Limit.” Or something to that nature. If a registration person receives an insurance card that reads this, they need to go on offense.

Offensive Tactic #1: Start with a discussion with the patient immediately that although the hospital will bill the insurance for the services, they do not agree to the terms of this insurance card. Create a form letter that the insurance card can be scanned into that creates an admission agreement that states: XYZ hospital does not agree to the terms of this insurance card, and the patient understands that the patient’s insurance is out-of-network. Any charges including deductibles, co-insurance, copays, along with charges that are not contractually agreed to will be balanced billed to the patient. The patient agrees that they will pay for any balance-billed charges. Then ask the patient to sign the agreement.

Offensive Tactic #2: Immediately call the self-funded/employer sponsored plan and notify them that the patient agreed to the admissions agreement that they will be “balanced billing the patient” for any charges for an “out-of-network” admissions. Any further communications that attempts to prevent this billing will be considered a “tortious interference” with my business relationship with the patient. We would gladly welcome the opportunity to discuss a potential contract with your plan by calling XXX.

Defensive Tactic #2: After receiving a letter or EOB as mentioned above with the language of cease and desist all collection activity” or “accord and satisfaction” it is time to start sending letters to the plan and also the patient. This letter should contain language that the hospital does not agree to the terms the EOB or letter states because of no contractual agreement between the plan; and therefore, will follow our policies of balance billing the patient for the remaining charges along with any deductible, co-insurance, and co-payment. If the Offensive Tactic #1 was completed, mail this along with this letter and continue billing the patient.

Offensive Tactic #3: Call the patient to ensure that the legal counsel does not represent the patient interest and document that this question were asked of the patient. “I am calling to see if you have any legal representation. If you do not, we will continue to communicate with you.”

Offensive Tactic #4: As these plans start to appear more frequently at your facility, then it is time to assign a billing representative to oversee responses. This includes having conversations with the plan administrator and working out an arrangement or contract that is agreeable to all parties. Sometimes the best tactic is to negotiate.

Offensive Tactic #5: Update your billing and collection policy to include strong language for those contracts that are out-of-network. My suggestion for this language would be:

It is the patient’s responsibility to present at the time of admission, registration, pre-authorization or discharged any third-party-payer available to pay for services. XYZ will attempt to bill all third party payers for services provided. The patient is responsible for ensuring that XYZ and all doctors performing services are within network. If XYZ is out-of-network with the third party payer, the patient will be responsible for out-of-network charges including coinsurance, co-payments, deductibles, and also additional balances for being out-of-network that will be balanced billed to the patient. XYZ does not participate with the out-of-network reference based billing plans.

If all these offenses and defensive tactics fail, Americollect is here to help. Our legal team of professionals will communicate with the plan and the patient to ensure the account is paid-in-full. If you have any questions in-regards to reference based bullies, please call or email Shawn at 920-420-3420 or

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Pentatonix…I Mean, Hallelujah Penetration Test

By: Kenlyn T. Gretz, Ridiculously Nice President and CEO

An email arrives in your inbox with an attachment. It is from a partner that your healthcare organization does business with.  The attachment is generically named “report.xlsx” with the subject line “Your Request” and it is signed by Jeff Barker from, Warner Health Care Solutions.  You think to yourself, “Hmmm, I think we used a company named Warner a few years back.  Is this something our CFO informed me I would be getting an email on?   Should I open the attachment?  Should I reply to the email?”

October was Cybersecurity month and the more you are aware, the better!  The saying at Americollect is “think before you click” and we train our team on the importance. The email described above is often the start of a ransomware encryption engine that starts encrypting your documents and files in all of your healthcare computer file directories. Then a “hacker” will ask for money. This has been in the news recently and is occurring to healthcare systems around the United States. The FBI’s response has been, “Just pay the ransomed.”

The attachment discussed above had an embedded .exe file which runs when the attachment is opened. It may not display a “I Got You!”  The “report.xlsx” file may simply be blank, you close it down and delete email.  “Oh Good, nothing bad happened” – but it did. In the background the ransomware is spreading through your system encrypting every document it can find in every folder!  Five hours later, your IT Department calls you and asks, “Did you open an email that was suspicious earlier today?”

In January of 2016, Americollect received a 470 question document from the State of Massachusetts asking us about our security controls. As our IT started working through the questions, we realized we could “tighten” our security even more. So we started with the Duo Authentication for Citrix logins (Duo authentication for Citrix logins), sophisticated intrusion detection systems, stronger web filers, more complex password requirements, phishing testing, co-worker cyber security training and penetration test on internal, and external network access points. Additional resources were spent on this, because I would rather spend it on increasing our cybersecurity than paying some ransomware pirate or super expensive cybersecurity insurance.

We have had a few clients ask us about cyber insurance. Cyber insurance pays for the cost of notifying consumers if there is a data breach.  In my mind, this is too late, the damage is done.  It is kind of like preventive healthcare. Wouldn’t you rather spend money on getting healthy versus spending money on being ill? Require your vendors to prove their security with audits and certifications. This is where the money should be spent, protecting.

We hired an outside penetration test firm from Tampa, Florida named KirkpatrickPrice. KirkpatrickPrice has years of experience in this field and did a thorough job. They have “white hats” who, for simple terms, try to “break-in” to your networks. They also try to access as if they are already inside the network (co-workers) and try to break in to areas they don’t have access to. Our Network Administrator, Alex Hartlaub, explains that “white hats” are hackers for the good guys. Alex worked with the team to administrate the test and to review areas of improvement once the test was completed.  After thorough examination, we had a report which showed 11 areas of improvement.

In all cases, the “white hats” were not able to access any data.  The 11 areas of improvement were resolved within two weeks! We plan to continue to do the penetration tests to make sure we are ahead of all of the “hackers” who are continuously trying new things. Our client’s data is too important to risk a breach or hacking.

Take cybersecurity issues, hacking, data breach, and ransomware seriously and staying ahead of the attacks. Double check, even triple check, with your vendors to ensure they are doing everything possible to keep your patients information secure!