How does patient responsibility affect the economics of the contract?

This, by far, is the elephant in the room form most behavioral health providers.

Here’s another question that can dramatically change the way a commercial payer opportunity looks:

How much of the patient’s financial responsibility is actually collectible?

A payer may allow $175 for a service.

That sounds attractive.

But what happens when the patient has:

• A high deductible
• Significant coinsurance
• A large outstanding balance
• Limited ability to pay
• Coverage that changes frequently

The contracted rate doesn’t automatically equal collected revenue.

And the difference matters.

Organizations may spend significant staff time on:

• Benefit verification
• Patient estimates
• Statements
• Payment plans
• Collection calls
• Balance follow-up

That work has a cost.

So when evaluating a commercial payer, leadership should consider more than the contracted reimbursement.

Ask:

What percentage of patient responsibility are we actually collecting?

And:

What does it cost us to collect it?

Because a payer contract can look financially attractive at the claim level while producing a very different result at the cash-collection level.

The question isn’t simply:

“What is the allowed amount?”

It’s:

“How much revenue do we realistically expect to retain and collect?”

That’s a much better business question.