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It happens in restaurants all the time: You have a problem with your meal, so management waives the bill to make up for it. More often than not, everyone walks away satisfied.
Wouldn’t the same technique work in the hospital?
Some people may find the idea distasteful and crass when it comes to health care, but some risk managers say waiving the bill can be an effective strategy for making small problems go away. The key, they say, is to be very judicious in deciding how and when to comp the bill. Even those who swear by the technique say it is useful only in limited situations.
Steve Johnson, director of risk management for WellStar Health System in Marietta, GA, says waiving the bill is a good addition to a risk manager’s toolbox. He has used the technique for years and says it can be the perfect solution for cases in which the patient or family has a relatively small complaint. One of the best uses is a situation in which a visitor claims he or she was injured on hospital property, he says. In those instances, WellStar immediately offers to waive the costs of any immediate emergency care or assessments.
"It’s a little self-serving because it gives us the opportunity to get a clinical snapshot before the person gets off our campus. That can prove useful later on if he or she decides to sue," he says. "We’re not admitting liability. It’s a courtesy and a public relations gesture. The incident has just happened, so that’s the best time to smooth some ruffled feathers and get him or her immediate care without him or her worrying about the cost."
With some minor incidents — for example, a visitor trips and skins a knee — the immediate offer to waive the cost of care is all the patient wants, Johnson says. Those patients often are willing to sign a release saying they won’t file a lawsuit.
"On the other hand, how happy are they going to be if they fall on our property and then we send them a bill?" he says. "Even if we’re not talking about much money, it’s those little things that can set people off."
In addition to incidents happening on your own campus, Johnson says waiving the bill can be useful when you just want a minor claim to go away quickly and quietly — either because it is too small to spend time on or because you doubt the veracity of the claim. With a serious claim of medical malpractice or other wrongdoing, he doesn’t even consider waiving the bill. The bigger and more substantial the claim, the less likely the plaintiff is going to drop it because you waived the bill. In those cases, offering to waive the bill can seem crass and just anger the other party if you try to settle the matter that way.
That’s not to say, however, that you can’t waive the bill as part of the negotiating process. The tone in which you offer to waive the bill can make a huge difference, Johnson says. In small cases, you may want to make it clear that you expect the matter to be closed entirely when you waive the bill and even get a signed release to that effect. With bigger claims, you may want to present the comp as merely a goodwill gesture, as in, "Of course we’ll be taking care of all your hospital expenses here, so don’t worry about that."
Then you just hope that the offer smooths the waters a bit while you negotiate the rest of the settlement.
"We find it most useful with those iffy situations where you don’t think you’ve done anything wrong but you don’t want to chew up a lot of money and time to deal with it," he says. "If we’re looking at a case where we may have some true liability, I don’t think it’s morally or ethically right to waive the bill and expect them to sign away their rights just because you did that."
Johnson offers the example of a patient who complains to management that a nurse was rude. If Johnson’s investigation suggests that the story is true, he may think the patient deserves some sort of compensation.
"That sort of thing would not be a compensable claim, but sometimes you just think that we didn’t do right by that patient and we need to do something to make it up to him," he says. "We’ll go back to that person and say, Let us make this small gesture as a way of apologizing.’"
Another example would be miscommunication between the staff and the patient’s family that did not directly affect the patient’s care but nonetheless frustrated the family. Clinical matters are more difficult to judge, but Johnson says waiving the bill still can be appropriate in those. An example would be missing the call on a fractured arm.
"They go away with pain and find out later that it’s fractured," he says. "We look at the film and realize we just flat out missed the call. Now the patient hasn’t really suffered because the treatment is the same in the end, so I wouldn’t call it a compensable claim with liability. But if the patient has some out-of-pocket and walked around in pain for a couple days, I have no trouble covering those expenses."
On the other hand, if the orthopedic surgeon says the missed diagnosis and delay caused a permanent problem with the arm, that’s a different situation, Johnson says. That rises to the level of a significant, compensable claim and he would not expect to close the claim by waiving the bill.
Many insurers recommend waiving the bill as a way to respond to some complaints. Western Professional Insurance Co. (WPIC), for instance, advises its clients that many patients and family members will see waiving the bill as a compassionate gesture. To help you get the right tone when waiving the bill, the insurer offers a sample letter that can be used to notify the patient and document the action. This is part of the letter that WPIC recommends:
"We reviewed and investigated your billing concerns regarding your [insert specific treatment, exam, or procedure] on [insert date]. We regret that you feel the care given was not satisfactory. The anxiety and frustration you described does not represent the level of service we strive to provide our patients.
"Following a thorough review of the medical records and discussion with clinical personnel, we believe that the care you received was appropriate. [Consider personalizing this letter by inserting specifics about the results of the investigation.] However, in the interest of goodwill and on behalf of XYZ Medical Center/Clinic/Physician, I would like to discount/waive the charges on your account.
"The time and effort you have taken to bring these concerns to our attention is greatly appreciated. We take feedback from our patients very seriously, as it provides an opportunity for us to review and improve the services we provide.
"We hope that you are doing well at this time. Please contact me if you have further questions or comments."
More advice from WPIC can be found on its web site at www.physins.com.
Modesty and humility are essential when making the offer, Johnson says. Avoid sounding like you’re making a grand gesture and expecting the recipient to be ever so grateful.
"We really see it as a way to do right by people, not as a tool where we’re trying to avoid responsibility for serious errors," Johnson says. "It can be exactly what you need in these situations because the compensation fits the level of the problem and both sides feel satisfied. Patients often just want some acknowledgment that you took their claims seriously."
There is usually a short window for deciding to waive the bill, Johnson says. This is a tool best used when the complaint is brand new and people haven’t had a chance to stew over it and get entrenched with the idea that they’re due a big payoff.
"Do this before it gets to the claim level," he suggests. "This is more the thing to do when they first come to you and say they’re unhappy. You might end it all right there if you act quickly."
Johnson has the authority to waive health care bills with just a simple call to the billing department. It’s a good idea to send the patient written confirmation that the bill has been waived, he says. The largest bill he has ever waived was about $2,000. Bills in the hundreds of dollars are not a big deal, but waiving thousands of dollars would require serious consideration.
On many occasions, however, Johnson tries to stay behind the scenes when a bill is waived. A nurse manager may call him and explain that a patient was treated poorly, for instance, suggesting that the hospital should not bill for services. If Johnson agrees, he authorizes the waiver and the nurse manager tells the patient. That can keep the patient from getting the idea that the risk manager fears a lawsuit.
Even if waiving the bill is a good idea strategically and morally, there may be reasons not to, says Leilani Kicklighter, RN, ARM, MBA, DASHRM, president of the Kicklighter Group consulting firm in Tamarac, FL, and a past president of the American Society of Healthcare Risk Management. With the increased attention to health care fraud and compliance issues, waiving the bill may not be a simple solution.
"It used to be easier to do these things 10 years ago," she says. "Anytime you’re going to do something like that in this day and age, you need to touch base with your compliance officer to make sure it’s alright. These issues can get very scary when you’re dealing with fraud and abuse."
Medicare regulations, for instance, prohibit billing for substandard care. So Kicklighter wonders if waiving the bill would be a form of compensation and be considered "billing" for care since that money took the place of other money you might have paid out otherwise. It’s all very confusing these days, she says.
Kicklighter cautions that health care providers may be waiving bills more than risk managers realize. Various levels of administration within the health care system may be in the habit of waiving bills without the issue ever reaching the risk manager, she says. That’s dangerous, even if you would have made the same decision in the end.
"At a minimum, the risk manager should be involved in these decisions so that you know what’s going on in your organization," she says. "You need to know if you’re getting the same complaints from some department or if one claim represents more of a risk than the other administrator realizes. There must be some policies and procedures in place so that this is done in an organized way with input from the risk manager and compliance officer, no matter how small the sum of money in question."