Collecting just got harder

But cures often come with side effects. You'll find that out when you try to collect from a patient who has an HSA.

The problem? This patient also will have a high-deductible health plan. It forces him to assume more financial responsibility for his care, which sounds good in theory. But, you may not get paid for months, or not at all.

Right now, that picture is misleading. Most high-deductible plans coupled with HSAs are preferred provider organizations (PPOs), which sets the stage for plenty of insurance company intrusion. A PPO's discounted fee schedule, for example, dictates how much network doctors can collect. And many of these plans tell physicians not to collect anything from the patient at the time of service. Instead, you're supposed to submit the claim to the insurer and wait for an explanation-of-benefits statement. Physicians are then free to chase down the patient for any money he owes.

"Having to bill the insurer and then the patient will drag out payment," warns pediatrician Richard Lander in Livingston, NJ. "I see this as a terrific financial burden."

It's not as if doctors like Lander haven't billed PPO patients before. The problem lies with deductibles that are increasing to $1,000 or more. Collecting from patients will become that much more laborious-more statements, more phone calls, more nagging in general. And with HSAs vulnerable to abuse (see "How do I stiff thee? Let me count the ways," ), the situation doesn't bode well for the doctor-patient relationship, either.

"What we have is an insured patient who is really a self-pay patient up to a very high deductible," adds Deborah Walker, a Surfside, CA, consultant with the Medical Group Management Association. "It's going to cost doctors extra to go after these dollars, and their accounts receivable will increase. Unless we can collect at the time of service, this is a step backwards."

There's a fix for this looming A/R problem: Information technology connecting doctor, insurance company, and custodian to the HSA account would permit real-time claims processing and payment in the doctor's office. Instant cash would eliminate billing statements and drastically improve A/R. But such connectivity won't become widespread until at least 2006, according to industry observers.

In the meantime, there are a few things you can do to cope with HSA hassles. Here's our minimanual on collecting your fee in the world of consumer-driven healthcare.

New insurance product-same old rigmarole HSAs, which debuted in January 2004, are hot. By last September, almost 245,000 people had signed up for them, according to a trade group called American's Health Insurance Plans. A Boston firm called Financial Research Corp. estimates that there'll be 8.2 million HSA accounts by 2010.

Increasingly available from insurers, HSAs can be used to pay any healthcare expense that's considered a qualified medical expense for tax purposes. By federal law, they must be combined with a health plan that has a minimum deductible of $1,000 for individuals and $2,000 for families. Because they pay lower premiums for such plans, many employers put some of their savings in an employee's HSA. Employees also can fund them with pre-tax payroll deductions.