Money Talks: Discussing Cost with Patients Before Treatment Is a Win-Win

Ralph A. Gambarella, MD, Chairman and President of Kerlan-Jobe Orthopaedic Clinic, and a member of The Doctors Company's Orthopedic Advisory Board.

“My knee still hurts after surgery, and I’m getting all these bills to pay that I didn’t know about.”

I thought it was going to be another typical day at my practice, but I found myself comforting an upset and frustrated patient who was still having a hard time returning to golf three months after having an arthroscopic medial menisectomy. “What had I done wrong?” I asked myself.

“Mr. Jones” had made an appointment to see me after twisting his knee trying to kick a soccer ball around with his grandson. He was 62 years old and already had been treated by his primary care physician with medicine and therapy but had remained symptomatic with a torn medial meniscus on MRI. He was miserable because he had not been able to play golf and couldn’t even keep up with his wife on their evening walks. He was overweight, with a varus knee and early osteoarthritis on weight-bearing x-rays and MRI.

Of course, his internist and friends had told him that he needed an arthroscopic surgery and after that he would be all better.

Despite counseling him that he might still have knee pain after a meniscectomy due to the underlying arthritis, we agreed that an arthroscopic surgery was in his best interest to try to improve his lifestyle. We discussed all the medical and surgical risks and postoperative rehabilitation program. I connected him to my surgery scheduling team after carefully and clearly explaining his medical diagnosis and treatment.

I thought I had done a good job—but I was wrong. I had neglected to make sure he had been advised of all the growing financial obligations that our patients face today.

When the pain didn’t resolve completely after surgery—and Mr. Jones was receiving bills he hadn’t expected—I had an unhappy patient.

Miscommunication Can Lead to Claims

Patient-physician miscommunication issues such as this one play a large role in contributing to malpractice claims. The Doctors Company has studied thousands of closed claims in various specialties and found that poor communication between the provider and the patient or the patient’s family is one of the key factors behind lawsuits. This issue contributes to 12 percent of cases for hospitalists and orthopedists and 14 percent of cases for obstetricians and emergency medicine providers.

A key component of good communication with patients is a discussion about financial obligations for the medical services provided. Good communication up front can help, especially if a surgical outcome or treatment does not lead to a perfect outcome.

Increasing numbers of physicians are joining large medical groups with a business manager or becoming hospital employees, which typically decreases their involvement with the business portion of healthcare. Most major medical insurance companies continue to sell policies with varying deductibles, co-payments, and complex rules. Unfortunately, these factors have led to an increasing disconnect between the patient and the physician when it comes to discussing financial obligations.

The physician needs to be involved in making sure that the patient is informed and educated about the financial burden of surgical and medical treatments. Doing this before proceeding with treatment can help lower the risk of a malpractice claim even when the medical outcome doesn’t meet the patient’s expectations. Understanding the financial commitment up front allows patients to make a more informed decision for care.

How to Ensure Financial Disclosure

In our office, we have established a series of steps for our patients once the patient has decided to proceed with elective surgery. These steps can be adjusted for non-surgical specialties:

  • At the time of the office visit, the office staff provides the patient with a surgical information packet that includes a direct telephone number to the physician’s care coordinator (PCC). The staff tells the patient to contact the PCC once he or she has decided to proceed with surgery.
  • The patient and physician also complete three forms with information that a staff member then enters into our electronic medical record:
    1. Surgery procedure form, completed by the physician with the appropriate CPT and ICD-10 codes.
    2. Anesthesia medical questionnaire form, completed by the patient.
    3. Durable medical equipment (DME) form, completed by the physician.
  • If the patient then contacts the PCC to proceed with surgery:
    1. The PCC contacts the insurance provider. If precertification is required, the office notes this and sends other data (MRIs, etc.) to the provider to authorize.
    2. The PCC then confirms the provider authorization.

Once the insurance provider has certified surgery, the PCC will contact the patient to schedule a surgery date and ensure that, if needed, the patient will obtain an appropriate medical clearance by their primary care physician (or a local physician to whom the patient is referred if the patient does not have a primary care physician). The physician must complete the clearance by the time of the preoperative office visit. The type of medical clearance required, if any, is determined by the criteria set by the anesthesia medical questionnaire form.

The PCC then sends the correct surgical date, CPT codes, and ICD-10 codes to: 

  • Office financial advisor: This advisor will discuss the patient’s insurance plan, deductible, and co-pay; establish the surgeon’s fee based on the expected procedure; and require a patient deposit at the time of the preoperative office visit. The deposit amount is designed to minimize the need for patient refunds due to overpayment post surgery.
  • Surgery center: The surgery date will be set and the surgery center financial advisor will contact the patient and discuss the patient’s insurance plan, deductible, and co-pay; establish the facility and anesthesia fees based on the expected procedure; and require another patient deposit prior to the date of surgery.
  • DME company: A private DME company will contact the patient and discuss payment costs and options for the DME requested by the physician.

It is incumbent upon the physician to work with his or her entire office and, where applicable, the surgery center team to provide patients with both the medical and financial information they need to make an informed decision prior to an elective surgery or other medical treatment.

By paying attention to both the medical and financial details, we are more likely to have happier patients, physicians, and surgery centers. Realistic medical and financial expectations discussed prior to elective surgery or other medical treatment can result in better efficiency, better outcomes, and less litigation.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.


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