In the ED, access' timing is everything
Higher skill set is required
Even though the number of self-pay and underinsured patients continues to grow at Northwest Community Hospital in Arlington Heights, IL, the patient access department set a goal of increasing emergency department (ED) collections by 50%.
"It is an ambitious goal, but we are dedicating more resources to make it happen," says Laura Kowal, director of access services. "About 85% of our bad debt is coming from our ED. It is not just self-pay patients; it is also patients not paying their copays or deductibles."
The hospital has collected payments in the ED, which sees more than 75,000 patients a year, for five years, but recently expanded these efforts. "We already had the mechanisms in place. Getting the physicians more involved was our next focus," says Kowal.
Physicians are key
Excellent communication between access staff and ED physicians is the only way to get the timing right, in terms of when financials can be discussed with a patient. ED physicians use a tracking board to alert access staff that the medical screening examination (MSE) required by the Emergency Medical Treatment and Labor Act (EMTALA), is completed.
"Our registrars and access specialists in the ED float around the whole area, monitoring the tracking board. They are basically dispatched, based on flow and timing and length of stay in the area," says Kowal.
If the doctor indicates that access staff are cleared to talk with the patient, but the patient is already on the way out the door, that doesn't do any good. Likewise, if a doctor doesn't take the time to update the tracking board for individual patients, but instead updates it with five or six patients at once because it's more convenient, the registrar cannot meet with every one of those patients.
"So if the patient has been there awhile, staff will look at what [his or her] initial diagnosis was coming in. They are proactive in saying, 'How's that patient coming along? Is the patient going to be going home?' So we have follow up," says Kowal. "It's a process that we have that is working."
The arrangement benefits the ED doctors as well, as they are an independent group. "We are assisting them with their collection efforts as well. It really is a partnership with the physicians," says Kowal. "The patient is not going to wait around for you or stand in line to meet with you to make their payment. We know we need to be following the patient."
When the board says that the patient is being discharged, the access specialists immediately meet with that patient to discuss financials.
"That's the first level," says Kowal. "If our patient has large amounts of debt with outside collection agencies, we also engage the financial counselor."
The access specialist asks for the money upfront, and begins the financial assistance application process with the patient. Next, an appointment is scheduled for follow up with a financial counselor, if one is not immediately available.
Some copays are $500
The first step in the process is to ask for payment from the patient. "Whether it's their coinsurance, copayment, or if they are self-pay, we will ask for that deposit right upfront," says Kowal. "Based on how the patient responds, that will drive the next step in our process."
An indicator tells whether the patient has already qualified for financial assistance, which is effective for a six-month period. If so, staff ask for the discounted amount. "Currently, we are collecting on about 75% of our patients who are eligible to collect from," says Kowal.
Access staff bring a wireless terminal into the patient's room so they can take payment by credit card. "That has really been key," says Kowal. "Also, if our patient starts a financial application process with us, we qualify that as initiating the payment. That doesn't mean they have returned it. But if the patient asks for the application and we begin the process, we know we are one step further along."
The department is seeing steep increases in copayment amounts. "There is one payer in our area that has an ED copay of $500. That is a phenomenon that we are now seeing," says Kowal. "We always ask for the whole amount, but often the patient doesn't realize [his or her] copay had gone up. We at least try to get something."
The patient is asked for a minimum payment based on the diagnosis. "For our 'frequent flyers' that are coming into the ED, we have a clinical resource specialist, which is similar to a case manager. That individual is assigned to work specifically with those patients," says Kowal.
A patient's record is flagged based on the number of ED visits in the past three to six months. "The goal is to hopefully help them find an area of care that best fits their needs. That may be at the federally funded clinic across the street from the hospital," says Kowal. "We are referring patients there for follow-up care who are underinsured or uninsured and may not qualify for public aid. We even assist them by scheduling an appointment there for the following day."
Degree is required
Previously, the financial counselor was the only person who discussed financials with ED patients. That has changed due to the rising volume of underinsured and self-pay patients. Access specialists now take on some of the financial counseling role.
This is one example of how the access role has changed dramatically in the past three to five years. "Our staff are really becoming forensic people," says Kowal.
If an ED patient cannot produce a valid ID, and offers an address and phone number, staff do electronic verification of that contact information on the spot. They also check medical records to see if there is documentation of returned mail or a bad phone number from the hospital's collection department.
"If the patient still says a phone number is valid, we will dial that phone number while the patient is standing there to see if we get a connection," says Kowal. "If the information isn't valid, we have that discussion with the patient as well. That is a part of our financial piece that happens at the end of registration."
Staff also evaluate the patient's propensity to pay, complete estimated payments, and ask patients for money. "The job is outgrowing some of our staff," says Kowal. "There are many changes that are occurring in the front end of the revenue cycle."
For this reason, the department now requires a degree for access services staff, regardless of where they work in the hospital. "It is not only the technology," says Kowal. "You are having that higher-level discussion with patients in much more detail. We think that one of the keys to improving our financials of our ED is having the higher level of employee."
[For more information, contact:
Laura Kowal, Director, Access Services, Northwest Community Hospital, Arlington Heights, IL. Phone: (847) 618-4595. E-mail: [email protected].]
Even though the number of self-pay and underinsured patients continues to grow at Northwest Community Hospital in Arlington Heights, IL, the patient access department set a goal of increasing emergency department (ED) collections by 50%.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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