Unfortunately, every practice has its share of deadbeats, whom I define not as patients who fall on hard times and are unable to pay, but those who are able to pay and do not.

The worst kinds of deadbeats are the ones who not only don't pay you, but accept checks from insurance companies

The best way to deal with them, however, is to prevent them from owing you money in the first place.

Whenever possible, require all payments at the time of service. In the case of elective surgeries, require a substantial deposit in advance, with balance due at the time of service. When that is impossible, maximize the chances you will be paid by ensuring all available payment mechanisms are in place.

In two previous columns I've described how hotels, rental car companies, and other businesses record credit card information to ensure that they will be paid, and I've shown you how to do the same thing. (If you missed those columns, go to www.skinandallergynews.com and click on "The Archive Collection" on the left-hand side.) Patients who fail to pay their credit card bills are the credit card companies' problems, not yours.

For big-ticket cosmetic procedures where you anticipate the fees will exceed credit card limits, arrange a realistic payment schedule in advance, and have the patient complete a credit application. You can find forms for this online at allbusiness.com, lawdog.com, and other sites. (As always, I have no financial interest in any product or business mentioned in this column.)

In some cases, it may be worth the trouble to run a background check. There are easy and affordable ways to do this. Dunn & Bradstreet, for example, will furnish a report containing payment records and details of any lawsuits, liens, and other legal actions for as little as $30. The more financial information you have on file, the more leverage you have if a patient later balks at paying his or her balance.

Always take before and after photos, and have all patients sign a written consent giving permission for the procedure, assuming full financial responsibility, and acknowledging that no guarantees have been given or implied. This defuses the common deadbeat tactics of professing ignorance of personal financial obligation and/or dissatisfaction with results.

Despite all your precautions, deadbeats inevitably will slip through on occasion. However, even then you have options in dealing with them.

Collection agencies are the traditional first line of attack for most medical practices. Ideally, your agency should specialize in handling medical accounts, so it will know exactly how much pressure to exert to avoid charges of harassment. Delinquent accounts should be submitted earlier rather than later to maximize the chances of success; my manager never allows accounts to age more than 90 days, and, if circumstances dictate, she refers them sooner than that.

When collection agencies fail, think about small claims court. You'll need to learn the rules for filing in your state, but most charge a nominal fee and place a limit of $5,000 or so on claims. No attorneys are involved. If your paperwork is in order the court will nearly always rule in your favor, but it will not provide the means for collection. In other words, you'll still have to persuade the deadbeat to pay up. However, in many states a court order will give you the authority to attach a lien to property, or garnish wages, which often provides enough leverage to force payment.

What about the deadbeats who rip you off twice--by refusing to pay and then stealing the insurance check, too? First, check your third-party contract; sometimes the insurance company or HMO will be compelled to pay you directly and then go after the patient to get back its money. (They won't volunteer this service, however. You'll have to ask for it.)

If that's not an option, consider reporting the misdirected payment to the Internal Revenue Service as income to the patient, by submitting a 1099-miscellaneous income form. Be sure to notify the deadbeat that you will be doing this. More often than not, the threat of such action will persuade the patient to pay up; but if not, at least you'll have the satisfaction of knowing he or she will have to pay taxes on the money.

DR. EASTERN practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, write Dr. Eastern at our editorial offices or e-mail him at sknews@elsevier.com.