Patients demanding out-of-pocket info

Need to know is greater

Patient estimation software implemented in late 2009 at Tallahassee (FL) Memorial Hospital has "helped tremendously" with collections, says Joan S. Braveman, director of patient access and financial services. "In this past fiscal year, we increased our front-end cash collection by 40%," she says.

Staff can give patients an accurate estimate of what they'll owe for any payers whose contracts are built into the system, says Braveman. Some patients have insurance, but the contracts are not built into the system, she adds.

For this scenario, Braveman says that staff are given specific individuals to contact at the insurers, so staff can call to find out what the allowed amount will be.

Multiple copays

Inaccurate estimates may occur, though, when a physician schedules a procedure or surgery and ends up doing something different or doing additional work, says Braveman. "One area where this really is a big problem is radiology," says Braveman. "One of our major HMOs is now stacking copays."

If patients are scheduled for a CT scan of the abdomen, staff will inform them that they have a $100 copay for the procedure. This amount can suddenly change, however, if additional views are needed, says Braveman, because the HMO charges another copay for each view.

"The radiologist may look at it, and say that they really need two more views. The patient could end up having a $300 copay," says Braveman. "That is problematic."

For this reason, staff are very careful to explain that additional copays may apply if any additional work is done, says Braveman. "People may hear what they want to hear, though," she says. "To the patient, they had a CT scan. They don't see that something different was done. That has been one place we have had a lot of issues and patient dissatisfaction."

Braveman recalls that in previous years, some HMOs stacked copays for a period of time, but many eventually settled on obtaining a single copay per 24-hour period. A few years ago, though, one local HMO started this practice again, she says.

"If someone goes to the ED and has a CT while they are there, for example, two copays apply. Patients are often unhappy about this," says Braveman.

Avoid surprises

Due to larger out-of pocket-responsibilities, and "with consumer-driven health care, the need to address patient financial responsibility 'upfront,' is greater than ever," says Carol Triggs, MS, director of patient access at St. Joseph's Hospital Health Center in Syracuse, NY.

Out-of-pocket costs have risen for patients in both consumer-driven and traditional plans, notes Triggs. "Verification of the patient's insurance and accurate identification of a patient's out-of-pocket costs during the pre-registration process is critical," says Triggs. "We need to ensure that the patient encounters no surprises on the date of their visit, or at the time of their discharge."

Providing a link through patient access to financial assistance programs, for both the uninsured and the underinsured, is "more important than ever," adds Triggs.

Accurate estimates

Braveman says that her staff were reluctant to give estimates to patients, fearing these would be inaccurate. "They were kind of pulling numbers out of the air. Now, we have some real numbers to deal with," she says.

Braveman said that initially, scripting was used for point-of-service collections, but unpredictable patient responses made this difficult. "It's pretty hard to script something if you don't know what's going to come from the other end," she says.

Braveman says while the patient estimation software had a big impact, she credits most of the department's success to a better-educated staff. "We have done a lot of education, not just about the importance of cash collection at the time of service, but also about the revenue cycle in general," she says.

Braveman asked staff this question: "What happens to the $100 copay that you didn't collect when the patient walked in the door?"

"If we are only collecting 50 cents on the dollar, that $100 becomes $50," says Braveman. "The likelihood of the patient paying goes down, the further away from the service you get."

Positive reinforcement

Braveman sends an e-mail out to all of her staff every month, showing them how they did with collections. "We've kind of made this into a celebration. That has made a big difference," she says.

If someone does an exceptional job with collections, Braveman gives that person free movie tickets. When staff had an exceptional month with ED collections, she bought pizza for everybody.

"I'm not into incentivizing the program, because it's in their job description," says Braveman. "But doing that extra bit of recognition says that somebody's paying attention to what you're doing."

Not all staff have access to the payment estimation system, Braveman notes. "The reason we opted not to give it to all of them is to because you need the exact CPT code for what is going to be done in order to get an exact price," she explains. "If someone comes in and says, 'I'm here for a CT,' that doesn't tell them enough to be able to figure out what the copay is."

Different types of CTs have different reimbursements associated with them, Braveman explains.

Braveman notes that state regulations require that staff must provide a written good-faith estimate to any patient requesting this. "When that regulation first came out about two years ago, we got calls from patients all the time," she recalls. "There were so many that it got to the point that we had to set up a separate phone number for those calls. Patients would leave their information for someone to call them back."

Braveman recalls that back then, "people were absolutely out shopping. And for someone who is either uninsured, or has a coinsurance rather than a copay, it made a lot of sense. But we're not seeing that as much today."

One reason may be that staff now call patients in advance to give them an estimate of what they will owe. "This is an opportunity for people to ask questions," says Braveman. "I only have a couple of people that I allow to call patients. They are very talented and they don't need every word they say scripted."

[For more information, contact:

Joan S. Braveman, Director Patient Access and Financial Services, Tallahassee (FL) Memorial Hospital. Phone: (850) 431-6202. E-mail:]