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Key takeaways from this episode

• Use an ABN for services Medicare sometimes covers, not for services it never covers. Infertility and most erectile dysfunction treatment are statutorily non-covered, so no ABN is needed. Incontinence devices, home treatments and similar "sometimes covered" services are where the ABN applies.
• The ABN must be the current CMS form, specific to the date and the service, and signed before the service is provided. A generic or after-the-fact ABN does not shift liability to the patient.
• Commercial contracts often bar you from billing the patient for a covered service that gets denied. Ask for a patient-responsibility pathway when you renegotiate, and renegotiate every year, at least for a cost-of-living increase.
• Every patient has the right under HIPAA to pay cash and have you not bill their insurance. Tell them the payment will not count toward their deductible, then consider a discounted pay-up-front rate.
• Collect before the service, not after. Use eligibility checks to identify unmet deductibles and co-insurance, take surgical deposits, and keep a card on file. Medical debt rarely hits a credit report, so a bill sent afterward is easy for the patient to ignore.
• Take the collection conversation away from the physician or PA. Set a written policy, train front-desk staff on it (repeatedly, because the role turns over), and build in exceptions for continuity of care plus a charity application for patients who truly cannot pay.
• Build the culture on the basics first. Get good at co-pays, deductibles and deposits before adding retail-priced services such as incontinence chairs or laser treatments.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 300, recorded August 2026, with Scott Painter and Mark Painter of PRS Network.

What has changed with ABNs and patient collections

[00:00] Scott Painter: On this episode: ABNs and collecting money from patients. Welcome to episode 300 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter. Today we want to talk about ABNs and collecting from patients in all the different forms that takes: cash pay, co-insurance, co-pays. We haven't covered this topic in a while and wanted to circle back. Mark, what's new in ABNs and collecting from patients?

[00:47] Mark Painter: I don't know that I would say it's new, but the reality right now is a continued shift in payment from payers to patients, along with patients understanding that sometimes insurance isn't the best way to go. The furthest we've gone with this was probably in 2024 or 2025, when we spoke with the physician in Florida who was doing concierge medicine. But more and more we have patients who either know they aren't going to meet their deductible for the year, or who are seeking services that aren't covered, or aren't well covered, by their insurance.

That's why we brought up the ABN. In urology we have a number of services, like infertility and erectile dysfunction, where there is flat-out benefit non-coverage of treatment. Then there are other services, some of the incontinence treatments and home diagnosis or home care treatments, that are covered sometimes. The "covered sometimes" services, especially under Medicare, are the ones we need ABNs on.

Medicare has a specific pathway. There is a form you download from the Medicare website. It has to be filled out for that particular date of service, it has to describe the services you're providing, and it has to be signed before the treatment is provided. For services you believe strongly Medicare won't cover, that shifts the responsibility to the patient.

Your private payer contracts may have different rules. Many have language that effectively bars you from charging the patient for services the payer might cover, with no separate pathway. That's something to look at changing when you go back and renegotiate, which we've recommended you do every year, at least asking for a cost-of-living increase.

Why patient balances are harder to collect, and what to do about it

[04:40] Scott: A question on that. With more responsibility shifting to the patient, and without much leverage on collections because a medical balance doesn't necessarily hit the credit report, are you seeing patient balances getting harder to collect?

[05:21] Mark: Add the economy to that too. Yes. Patients are routinely one of the hardest groups to collect from, and that's where timing and the conversation with the patient come into play. As a general policy: estimate costs for patients you know or believe have an unmet deductible, make sure co-pays are clearly noted, and take surgical deposits for deductible gaps and co-insurance. If you can get that information from your eligibility checks, use it to collect at least a deposit, or a deposit plus a credit card on file, or the full amount, before the service is rendered.

Too often, patients believe medical debt won't hurt their credit unless they're buying a house or making a large purchase, so they ignore the bill as they struggle month to month. It becomes a habit. You want to do as much as you can to collect up front.

I'd also remind everyone that the patient always has the right under HIPAA to request that services be provided without billing insurance. That is cash pay. A number of practices have set up a separate entity focused on men's health, women's health, or wellness services patients are already paying for elsewhere. When you offer that, let the patient know the payment probably won't count toward their deductible, and consider a discounted rate for payment up front so the service is paid for in a retail, patient-direct way. In the incontinence world there are plenty of services, magnetic chairs and some of the intravaginal laser treatments, that are provided to patients on a cash basis.

To make any of this work you need a few pieces in place. Your front-office people have to be trained to ask for and collect the information. You have to be able to process credit cards and hold a card on file. And you have to follow through on the patient's promise to pay so that revenue is easier to collect directly.

Large groups versus physician-owned practices

[10:20] Scott: Are the larger groups, the ones owned by corporations or private equity, better at collecting from patients? For the physician-owned groups, is it harder to say no when you're an owner?

[10:54] Mark: I can't say larger groups are on top of this any better than smaller private groups. The bigger issue is the culture of the practice and the size of the geography it serves. In smaller towns, and for solo practitioners, physicians see their patients out and about, and that makes those conversations more difficult. It's all over the board.

The biggest factor is the structure you lean into. A physician is, by nature, more concerned with providing care and making sure the patient is happy with the result. Putting that caregiver, or the PA, in the collection role is much harder. The further you can move collection away from the caregiver toward the front, and the more you can set it up on written policy, the easier it is for your staff to set the culture.

Many of you have heard me compare healthcare to dentistry. Dental care has been provided for years with much of the revenue coming directly from the patient. It's about the training. Some would argue healthcare is less optional than dental care, and that's true for cancer. But most urology practices also provide services that are life-improving but not critical, things like BPH and incontinence treatment, where the patient chooses whether to pursue them. That makes those services more retail.

So the policy doesn't have to be inflexible, but it should move collection off the caregiver, with exceptions for continuity of care and the things you're required to do, and with a charity application so patients who truly need care and can't afford it fall into that category. That gives the patient options and lets the practice take advantage of any tax treatment available.

[14:43] Scott: Those are great points. It's hard to slow down, put processes in place and train your people, but this is one area where it's crucial. Those policies, procedures and training are the ultimate protection. It's human nature: as a caregiver you want to see the patient healthy and treated, and that's a hard line to draw at the point of care. Having a policy so the person at the point of care doesn't have to have that discussion is the first thing to implement.

Fitting the approach to your market and your people

[16:02] Scott: What else is working with our groups? There's no one size fits all. You mentioned geography and population, and economics matter too. Things that work in a city or an affluent area may not work in the country or a poorer setting. How do you set this up?

[17:09] Mark: Two things need to be analyzed, and planning is the first step. Understand your market: where your patients come from and what financial wherewithal they have. You don't set up a plastic surgery clinic in an area that isn't affluent. Even with PPOs and IPAs aimed at blue-collar workers without a lot of disposable income, where healthcare isn't the top spending priority, you want the ability to collect co-pays and the basics.

If you think your market can support expanded retail-facing services, first get good at collecting co-pays, deductibles and surgical deposits so you build the culture up front. By culture I mean both the internal culture and the culture with your patients, getting them to understand that healthcare isn't free just because they have insurance.

On training, make it repetitive. These front-facing jobs turn over because they're higher stress and often not as well paid, so build repeatable programs and videos you can use to train replacements quickly. And look at your people. The friendliest front-desk person in the world is a great face to see, but if that person can't collect money, they may not be the one to retrain for it. It's about personnel, training, tools, and changing the culture of both your patients and your practice over time.

[20:51] Scott: It's worth repeating: it's much harder to collect from someone after their problem is solved than before. Putting the collection piece at the beginning, before the service, creates urgency on the payment side. Anything else before we wrap up?

[21:28] Mark: No, I think we've covered it.

Sponsors and closing thoughts

[21:31] Scott: We want to thank our sponsors for this episode. ModMed: if you're in the market for an EHR or practice management system, go to modmed.com/prs for specials for our listeners. And thank you to UroGen, manufacturer of Zusduri and Jelmyto; visit jelmyto.com or zusduri.com for more information. Mark, any final thoughts?

[22:11] Mark: The take-home message is that very few patients don't have to pay for their care, at least in part, every time they see you. Letting patients pass the front desk with balances and skipped co-pays, the basic blocking and tackling, is a serious hit to your top line and makes it harder to maintain the financial health of the practice. Whether or not you go full retail, spend the time and management energy to get the processes, procedures, training and tools to the people who are in a position to collect what's due. Very little in this country is free, and there is no such thing as free healthcare. Somebody is paying: you, the insurance company or the patient. Making sure it isn't you, unless you choose that through charity, is part of maintaining a healthy practice.

[23:52] Scott: Great advice. A reminder that the Urology Advanced Coding and Reimbursement Seminar is coming up in December in Las Vegas and in January in New Orleans, where we cover a lot of these topics and you can spend two days learning from the PRS experts and from your peers. The PRS Coding and Reimbursement Hub is also available at prsnetwork.com/urologyhub, with coding advice by category and by product, and we're adding to it every week. That's all for today. Thank you for listening. Take us out, Mark.

Mark: Happy coding, and collecting.

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