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To study the use of e-visits in a primary care setting. A pilot study of using the Internet for online care (“e-visits”) was conducted in the Department of Family Medicine at Mayo Clinic in Rochester, MN. Patients in the department preregistered for the service, and then were able to use the online portal for consultations with their primary care physician. Use of the online portal was monitored and data were collected from November 1, 2007, through October 31, 2009. During the 2-year period, 4282 patients were registered for the service. Patients made 2531 online visits, and billings were made for 1159 patients. E-visits were submitted primarily by women during working hours and involved 294 different conditions. Of the 2531 e-visits, 62 (2%) included uploaded photographs, and 411 (16%) replaced nonbillable telephone protocols with billable encounters. The e-visits made office visits unnecessary in 1012 cases (40%); in 324 cases (13%), the patient was asked to schedule an appointment for a face-to-face encounter. Although limited in scope, to our knowledge this is the largest study of online visits in primary care using a structured history, allowing the patient to enter any problem, and billing the patient when appropriate. The extent of conditions possible for treatment by online care was far-ranging and was managed with a minimum of message exchanges by using structured histories. Processes previously given as a free service or by nurse triage and subject to malpractice (protocols) were now documented and billed.

Millions of uninsured Americans rely on hospital emergency departments (EDs) for medical care. Throughout the United States, uninsured patients treated in or admitted to the hospital through the ED receive hospital bills based on what hospitals call \"billed charges.\" These charges are much higher than those paid by insured patients. In 2006 California approved \"fair pricing\" legislation to protect uninsured patients from having to pay full billed charges. We found that by 2011 most California hospitals had responded to the law by adopting financial assistance policies to make care more affordable for the state's 6.8 million uninsured people. Ninety-seven percent of California hospitals reported that they offered free care to uninsured patients with incomes at or below 100 percent of the federal poverty level. California's approach offers a promising policy option to other states seeking to protect the uninsured from receiving bills based on full billed charges. [PUBLICATION ABSTRACT]

In 2009, tax exempt nonprofit hospitals in the United States spent 7.5% of their operating expenses on community benefits, and more than 85% of those expenditures went to charity care. 2 However, a number of hospitals and hospital systems have been criticized for failing to inform low income patients that they may be eligible for charity care, for charging uninsured patients far more than they charge insured patients, and for using aggressive debt collection tactics on people who fail to pay their bills-in some cases, garnishing patients' wages and allowing debt collectors to confront patients in emergency rooms.

The government is unlikely to meet its target to recover £500m (€560m; $610m) a year from the cost of treating overseas visitors who are not entitled to free NHS hospital treatment by 2017-18, the National Audit Office has concluded. 1 The Department of Health in England launched a programme in 2014 to extend the scope of charging for overseas patients and implement existing regulations more effectively to tackle concerns that the NHS was \"overly generous\" to overseas visitors. 2 In a progress report, the NAO found that the total amount of income identified had almost trebled since the start of the scheme, from £97m in 2013-14 to £289m in 2015-16. [...]most of the increase (£164m) has been generated through a new immigration health surcharge, introduced by the Home Office in 2015-16, for students and temporary migrants from outside the European Economic Area and not through direct patient charging. Mark Porter, BMA council chair, said, \"While those accessing NHS services should be eligible to do so, systems to charge migrants and short term visitors need to be practical, economic, and efficient, and must not jeopardise access to healthcare for those who need it.

Background A smartcard is an integrated circuit card that provides identification, authentication, data storage, and application processing. Among other functions, smartcards can serve as credit and ATM cards and can be used to pay various invoices using a ‘reader’. This study looks at the unit cost and activity time of both a traditional cash billing service and a newly introduced smartcard billing service in an outpatient department in a hospital in Taipei, Taiwan. Methods The activity time required in using the cash billing service was determined via a time and motion study. A cost analysis was used to compare the unit costs of the two services. A sensitivity analysis was also performed to determine the effect of smartcard use and number of cashier windows on incremental cost and waiting time. Results Overall, the smartcard system had a higher unit cost because of the additional service fees and business tax, but it reduced patient waiting time by at least 8 minutes. Thus, it is a convenient service for patients. In addition, if half of all outpatients used smartcards to pay their invoices, along with four cashier windows for cash payments, then the waiting time of cash service users could be reduced by approximately 3 minutes and the incremental cost would be close to breaking even (even though it has a higher overall unit cost that the traditional service). Conclusions Traditional cash billing services are time consuming and require patients to carry large sums of money. Smartcard services enable patients to pay their bill immediately in the outpatient clinic and offer greater security and convenience. The idle time of nurses could also be reduced as they help to process smartcard payments. A reduction in idle time reduces hospital costs. However, the cost of the smartcard service is higher than the cash service and, as such, hospital administrators must weigh the costs and benefits of introducing a smartcard service. In addition to the obvious benefits of the smartcard service, there is also scope to extend its use in a hospital setting to include the notification of patient arrival and use in other departments.

Key Points Demonstrates the value of practice-based research to provide evidence from the 'real-life' clinical environment. The biggest influence on early failure of Class V restorations was the clinician who placed the restoration. The results suggest that good handling of restorative materials is more important than the type of material chosen. Some materials are less user-friendly than has been suggested. Objective To evaluate Class V restorations placed by UK general practitioners comparing those failing or surviving after two years, and to identify factors associated with early failure. Design Prospective longitudinal cohort multi-centre study. Setting UK general dental practices. Materials & methods Ten dentists each placed 100 Class V restorations and recorded selected clinical information at placement and recall visits. Univariate associations were assessed between recorded clinical factors and whether restorations had failed or not at two years. Multi-variable binary logistic regression was also undertaken to identify which combination of factors had a significant effect on the probability of early failure. Results At two years, 156 of 989 restorations had failed (15.8%), with 40 (4%) lost to follow-up. Univariate analysis showed a significant association between restoration failure and increasing patient age, payment method, the treating practitioner, non-carious cavities, cavities involving enamel and dentine, cavity preparation and restoration material. Multi-variable analysis indicated a higher probability of early failure associated with the practitioner, older patients, glass ionomer and flowable composite, bur-preparation and moisture contamination. Conclusions Among these practitioners, both analytic methods identified significant associations between early failure of Class V restorations and the practitioner, cavity preparation method, restoration material and patient's age.

Many medical practice employees find the collections tasks assigned to them to be a source of discomfort, reluctance, and even dread. This is understandable. Talking about overdue accounts is not something most people want to do. This article focuses on the three most effective strategies that medical practice employees can use to help them feel more confident when they handle patients who have overdue accounts. It provides a sample 135-day collection program and variations of it that many medical practices use. It offers medical practice employees 10 tips to help them develop a stronger, more businesslike attitude when they approach their collection duties. It provides a list of more than 15 daily affirmations that medical practice employees can use to develop a more positive attitude about making collection calls and having one-on-one collection meetings with patients. Finally, this article presents a worst-case scenario exercise to help medical practice employees face their worst fears about collection calls and meetings and to feel more at ease when they confront patients about their debts.

Health care providers are increasingly relying on collection agencies to recoup charges associated with medical care. Little is known about the prevalence of this practice in low-income communities and what effect it has on health-seeking behavior. Cross-sectional survey at 10 \"safety net\" provider sites in Baltimore, Md. Specific queries were made to underlying comorbidities, whether they had a current medical debt, actions taken against that debt, and any effect this has had on health-seeking behavior. Overall, 274 adults were interviewed. The average age was 43.9 years, 77.3% were African American, 54.6% were male, 47.2% were homeless, and 34.4% had less than a 12th grade education. Of these, 46.2% reported they currently had a medical debt (average, 3,409 dollars) and 39.4% reported ever having been referred to a collection agency for a medical debt. Overall, 67.4% of individuals reported that either having a current medical debt or having been referred to a collection agency for a medical debt affected their seeking subsequent care: 24.5% no longer went to that site for care; 18.6% delayed seeking care when needed; and 10.4% reported only going to emergency departments now. In the multiple logistic regression model, having less than a 12th grade education (odds ration [OR], 2.5; 95% confidence interval [CI], 1.0 to 6.0) and being homeless (OR, 4.1; 95% CI, 1.4 to 12.3) were associated with a change in health-seeking behavior while having a chronic medical condition (OR, 0.2; 95% CI, 0.1 to 0.5) and going to a community clinic for usual care (OR, 0.2; 95% CI, 0.1 to 1.0) were protective. Aggressive debt retrieval for medical care appears to be indiscriminately applied with a negative effect on subsequent health-seeking behavior among those least capable of navigating the health system.

\"Here in Alberta, I'm getting calls quite regularly about clinics charging for sick notes and facility fees or bills to cover clerical things,\" says David Eggen, executive director of Friends of Medicare in Alberta. \"It's been an ongoing story in Alberta since early this summer. ... Has the scope of insured fees narrowed so much that doctors have to make the extra up through other fees?\" \"We're talking $15 for most of these services,\" says Dr. Bruce Rosenberg, vice-president of business development for Healthscreen Solutions Inc. \"You hear people saying doctors are gouging their patients, but I don't see how that's gouging. I think that's a great bargain.\" \"We can't say to a physician that it's wrong to charge for an uninsured service,\" says [Danielle Martin], a family physician. \"But we can't forget what the spirit of the public system is supposed to be about, which is when you show up in need of health care, you don't get asked to open your wallet. These things are nibbling away at the edges of that.\" - Roger Collier, CMAJ

Back in the day when deductibles and copayments represented a relatively small share of your accounts receivable, you might have been able to get away with relegating patient-balance collections to your secondary list of practice management priorities. But in today's world of flat or declining medical revenue--coupled with burgeoning consumer-driven health plans--collecting those patient dollars has become a significant part of revenue cycle management.