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Growing focus on ED collections: Here are tips
Obtaining copays and accurate insurance information in the emergency department is not easy - and, therefore, is often not done. The department is not only hectic, but the Emergency Medical Treatment and Labor Act (EMTALA) also presents obstacles unique to the ED.
However, ED collections are becoming more important to the hospital's bottom line - and patient access is being charged with revamping the collections process.
"There is a great opportunity for collections on the front end," says Sandra N. Rivera, RN, BSN, director of patient access at St. Joseph's Wayne Hospital/St. Joseph's Regional Medical Center. "Pushing collections to the front end allows for an increase in collections prior to the bill being generated and reduces the number of days for expected payment."
Rivera says that it's helpful to develop a process for staff to be able to view outstanding balances and let the patient know their responsibility.
Challenges are many
"The ED is a busy and oftentimes hectic place," says Frank Danza, vice president of revenue cycle management at North Shore-Long Island Jewish Health System. "Securing complete and accurate insurance information, collecting copays, and making sure that the patient understands their responsibility and their financial assistance options is not easy to complete in the time that an ED treat-and-release patient is in our facility."
For this reason, North Shore-Long Island Jewish's patient access staff is focusing on patients as they exit, as well as when they enter the process. Before the patient leaves the facility, patient access staff makes sure to cover these areas: reviewing personal information such as address and contact information, confirming insurance information, collecting copays, and reviewing financial assistance options for self-pay patients.
"While we have had modest staff increases to perform this function, we have achieved efficiency in the process by providing our staff the right education and tools to get their jobs done," says Danza.
According to Suzanne Frank, director of revenue cycle at Wheaton Franciscan Healthcare-Iowa, the three biggest challenges of ED collections are that they are not "patient friendly," they cannot be done at the point of entry, and physical barriers.
"Many EDs - including ours at Covenant Medical Center - are not set up in a conducive manner for collections," explains Frank. "We have multiple exits, making it difficult to capture patients at the point of departure."
Frank says that her department has done a lot over the last year to get copay collections and self-pay deposits upfront at Covenant Medical Center, largely focusing on staff training. "Our ED visits have continued to increase, as many hospitals are experiencing," says Frank.
Patient access staff attempt to collect the payment after the patient is treated in the ED. If patients express concern over their ability to pay, they are immediately referred to a financial advocate working in the same area for assistance.
ED collections are a frequent topic of discussion at staff meetings, with individual staff members discussing experiences and celebrating successes.
"We provide open discussion, scripting tools, and process flow tools to the associates," says Frank. "At this time, we're looking at both dollars and the number of collections to measure our efforts. Over the last few months, we've seen a steady increase in both measures due to the team's efforts in that area."
Care can't be delayed
"Collections in the emergency department must not delay any clinical care," says Rivera. "Providing clinical care of the patient must be the No. 1 priority."
This ensures compliance with state and federal regulations, says Rivera, as well as the mission of the hospital.
"Once the patient has been medically screened and stable, some institutions may attempt to collect or notify the patient of their payment responsibility," says Rivera. "This can be challenging depending on the disposition, or lack of final disposition, of the patient."
Rivera says that the process of collecting after discharge appears to address EMTALA guidelines and avoid any collections from patients that are to be admitted. "Collections are based on the patient's commercial insurance cards, and are for treat-and-release patients."
Having a patient tracking tool or automated process to track these patients can greatly help your registration staff follow up on patients, once they have been discharged but before they leave the ED, adds Rivera.
If this is not available, a manual tracking process can be set up to flag the chart once the patient is ready for discharge, so that the registrar can follow up on the co-pay collections. "The support of the clinical staff is essential when you do not have an automated tracking process," says Rivera.
The floor plan or geographical set-up of the department also can present challenges regarding patients leaving prior to having financial clearance. "EDs with multiple exits can allow for this to occur," says Rivera. "The set-up of a financial discharge point can assist to resolve some of this issue or having a specific employee designated to this task."
Rivera recommends that before starting an ED collections process, you make sure to have these "nuts and bolts" in place: a petty cash drawer, a drop safe, and software or credit card equipment to enable this process. "Depending on your institution, you may need to issue numbered receipts to the patients and maintain a log that is reviewed by management and the cashier to maintain controls," she says. "Keeping track of your collections in a scorecard or report to monitor your progress is essential."
You will need to come up with a benchmark for expected collections. This can be achieved, says Rivera, by collecting a copy of the insurance cards in the ED and obtaining an average of possible collections from the information on the ED copay. "This varies from plan to plan and should only be used as a guideline," says Rivera.
Several years ago, the patient access department at Long Island College Hospital of Brooklyn dedicated an employee specifically to ED collections.
"She collected an average of $700 to $1,100 a month - not a lot of money, but at the same time, she was able to reach out to many of the patients, helping them apply for Medicaid and giving them other options to make payments to the hospital," says Kathy Matthews, director of admitting and ED registration. "It was considered a promising start."
After only two years, however, staff turnover and other issues caused the program to falter. "Now we are building a business office devoted to the ED, in the ED, which will become operational in the next few months," reports Matthews. "We hope this will improve collections by being a more professional, permanent fixture in the ED."
The person who previously handled ED collections was from the hospital's Medicaid office. When that single position was eliminated, collections lagged. "Now, however, under a new administration, the issue was revisited and even upgraded to business office status," says Matthews.
The new ED business office will tackle the following:
enrollment in Medicaid or charity care programs;
booking follow-up clinic appointments;
referrals to the hospital's network of primary care physicians, if the patient lacks one of his/her own;
referrals to the hospital's specialists.
At Long Island College Hospital, admission from the ED comprises over three-quarters of inpatient volume. "So while treating the patient is important, the follow up while the patient is still in the ED is vital to future business," says Matthews. "In this way, we hope to maintain a connection to the patient and his or her future care, thus growing volume."
Most patients will pay
Once all care is rendered, Rivera says most patients will make the required payment. Those who are not able to are given a self-addressed envelope with a basic statement informing them of the copayment responsibility with the amount listed. "You will be surprised how many patients do mail this back," says Rivera.
The implementation of collections in the ED requires careful process change, says Rivera, including "training, training, training of frontline staff." You will need to give your staff the necessary tools to be able to approach the patient with information, including scripts on how to handle different scenarios.
Rivera's staff attended a training class, developed in-house, that included scripts and role-playing. "One of the key elements in collections is letting the patient know, 'This is the co-payment as required by your insurance company or your insurance contract,'" says Rivera. "If they are still unsure, it is also clearly documented on the patient insurance card. Take the time to explain and show them the fine print on the insurance card."
Technology can greatly improve this process, "but do not let it be a show stopper," says Rivera. "This can be implemented and you can achieve collections without technology."
Once you have "made the leap" into collections on the front end, Rivera advises setting up an incentives program for staff on the highest collections days for the month. St. Joseph's staff collections are tracked on a monthly basis, by using data in the log book.
"We are an inner-city hospital where you have to work every other weekend," says Rivera. "We have given an additional weekend off as an incentive for completing the highest copays, or the prize can be a preferred parking space. Staff are receptive to this and have enjoyed the competition."
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