Train reps to have a business mentality
Encourage them to assume larger responsibilities
Are your access services representatives monitoring just their registration cubicles, or are they also checking out the entire waiting room? Does your department keep statistics on incidents involving illegal aliens and closely question police when they bring in injured suspects? How about attempting to get an address — even if it’s just a street corner — for that homeless person who shows up in the emergency department every Saturday night?
The answers to those questions often distinguish an average access department from a good one, suggests Jack Duffy, FHFMA, corporate director for patient financial services at Scripps-Health, San Diego. The key is the ability to set up complete cycles in handling patient encounters, rather than starting over each day and closing the door at 5 p.m. on everything that happened in between, Duffy contends. He says it can make a difference in your organization’s bottom line.
"We in access are so episodic in our thinking," he says. "History is what happened last night. It’s that mentality of incompleteness."
In San Diego County and other areas on the U.S. border, it is generally the policy of the U.S. Border Patrol not to take custody of injured people who need emergency care, thus avoiding responsibility for medical charges, according to a 1997 report by the California Bureau of State Audits.
As a result, San Diego County health providers incur millions in unauthorized emergency medical treatment to unauthorized immigrants, the report states. (See related story, p. 140.)
The typical response of access services, Duffy points out, is to say, "It happens," and realize those unpaid charges will fall into the category of bad debt. Instead, he says, "the access manager on the front line has the primary responsibility to report these incidents, not blend them into the global debt. If things are ever going to change, it will be because statistics are kept."
The answer is accountability
If a police officer comes in saying he’s acting as a good Samaritan with a suspect who has five bullet holes, the access representative is well-advised to seek further information, Duffy says. "The answer is accountability. Get the name of the person who brings in [the injured person]. Was he accompanying the patient in the ambulance? What is his name? His badge number?"
That way, he adds, when the hospital sends a bill to the county or to the sheriff’s department, it can better illustrate a custodial relationship as opposed to a friendly ride to the emergency department (ED). In some instances, the access rep may need to go the extra mile, extending the interview process to other witnesses. Getting the details may strengthen the hospital’s position, Duffy says, as in, "If you were beating this guy up, we think that qualifies as his being in custody."
In the case of the Border Patrol and unauthorized immigrants, much of the value of documentation may be for its later use in supporting political change, he adds. "The state of California sued the federal government and said, An unsecure border is your problem, and you should be paying,’" Duffy points out. "It still is a national issue."
Gathering statistics and taking them through the bureaucracy to the decision makers is how policies change, he adds. "If it all goes under global bad debt, it doesn’t get solved."
One strategy for getting payment from illegal aliens, Duffy says, involves pushing a little harder for identification. "[The unauthorized immigrant] may give his brother-in-law’s address, so ask for a picture ID," he suggests. A couple of extra questions may establish that the patient’s permanent address is Tijuana, Mexico, Duffy notes.
Assume you’ll never see them again
After triage, when questions about finances are allowed, he suggests asking the uninsured person how he will pay for the medical care. "At Scripps-Health, we’ve attempted to set up procedures that assume this is the last time we’ll see that person," Duffy says. In some cases, he adds, registrars will tell the uninsured patient who has been brought in by friends or family, "Go out and collect $20 from every person in the car. That’s your charge for the night."
If studies show that certain groups never pay their bill, realize that "if we ever get paid, it’s going to be tonight," Duffy says. Too often, he adds, providers "build in" a certain amount of bad debt without considering innovative ways to reduce it.
Most patients don’t come in unaccompanied, Duffy points out, thus the question, "Are you monitoring just your registration cubicle, or are you monitoring the waiting room? The cash is in the waiting room. Who has arrived and what can they do to improve the amount of information you obtain or the funds you solicit?"
This philosophy also works well in the area of automobile accidents, he notes. If your patient was not at fault, then knowing things about him or her brings limited success in collecting payment, Duffy says. "What is the insurance of the driver of the other car?" Since coverage amounts are usually capped and funds are paid on a first-come, first-served basis, time is of the essence, he adds.
Get in line first
What’s important, Duffy notes, "is knowing that it was Lucy’s car that rear-ended [the patient’s car] and that she has insurance with State Farm, and where to send the bill." Also waiting for payment are the ED physician and the ambulance service, and if the hospital doesn’t get in line first, he says, the result may be more bad debt. "It’s very competitive, and it’s happening right there," Duffy adds. "It’s not something the business office can manage correctly."
At ScrippsHealth, four out of five pieces of returned mail are related to ED registration, Duffy points out, which leads to the question, "What are your policies on transients?"
When registering a patient without a real address, he says, ask pointed questions to find out how to locate that person if necessary. "Find out what the person’s route’ is," he suggests. "Ask, Where do you stay? What corner are you on? How do I get a message to you?’" Consider, Duffy says, that you might be able to get medical assistance funding for the person if you take the time to gather this information.
Noticing, for example, that the same homeless person comes in every Saturday night for treatment means that next Saturday night you could have an application for medical assistance ready to be completed, he adds.
"Do you have blinders on," Duffy asks, "and just see the person in front of the bullet-proof window for five to seven minutes, or do you really try to manage bad debt? Those with breakout thinking will do better."
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