Revamp collection process for admitted ED patients

Results can be dramatic

It's hard to imagine a tougher point-of-service collection challenge than collecting from emergency department patients. Patients may expect to pay a small copay, and when they change to inpatient status, may suddenly owe thousands of dollars toward their deductible.

"It seems that this is still quite a shock to many," says Maria Wence, corporate director for patient access at Lourdes Health System in Riverside, NJ.

ED is bigger challenge

At Children's National Medical Center in Washington, DC, patient access staff are trained to determine the patient's out-of-pocket responsibility during verification of insurance benefits, says Carole Helmandollar, executive director of ambulatory services.

If there is going to be a large out-of-pocket cost, staff refer the family to the hospital's financial information center to either apply for secondary Medicaid coverage if eligible, or apply for the hospital's charity care program under the financially indigent coverage offered, says Helmandollar.

"To qualify, their out-of-pocket expense for all medical services would have to exceed a certain percentage of their net income," notes Helmandollar. A third option is for staff to negotiate a payment plan, she says.

"Ironically, we sometimes also experience the reverse of this problem," says Helmandollar. "A parent has paid their ER copay, but when they're admitted, this is waived and they have no out-of-pocket expense. The family obviously wants their money back, but we aren't always able to resolve that request the same day. That can lead to customer service issues."

Lourdes Health System implemented a new upfront collections policy in May 2010 for most registration areas, focusing mainly on elective procedures, scheduled outpatients, and ED copays.

"As a result, we have seen a dramatic improvement in payments received from patients," reports Kim Barnes, the organization's vice president of corporate development. "The new processes implemented have had the most significant impact on payments received from scheduled patients." The collection of out-of-pocket payments for emergency department patients remains a bigger challenge, however, says Barnes.

"Year to date, our collections for one facility increased by 1,870%. Yes. 1,870%!" says Wence. "At our other facility, the increase was approximately 86%."

Major challenges

Wence says that the No. 1 challenge in collecting payments from emergency department patients is simply determining how much to collect.

While the patient's copayment is usually clear, other out-of-pocket costs and co-insurance payments can be quite complicated, Wence explains. "Just one insurance company may have dozens of products with different rates, and we work with a number of different insurers," she says. "Thus, estimating the correct payment to collect is the most difficult problem."

This is particularly challenging for patients being admitted to the hospital from the ED, says Wence. One reason is that the status of patients is often not known upon admission, and patients may move from observation status to inpatient status and vice versa, she says.

"This makes it almost impossible to determine the proper payment at the beginning of their stay," says Wence. "We are only focusing on the ED copay at this time. We have a set estimated average price that we ask from our self-pay patients."

The medical condition of patients being cared for in the emergency department is also "a huge challenge," says Wence. "Since the patients are very ill and in need of emergency care, they may not be capable of discussing payment for services," she says. "Patients and their families often are not prepared to go to an emergency department. They may not have their wallets or proper information."

Process changes

Patient access leaders instituted a process change in the emergency departments at Lourdes in 2010. "We now have a dedicated team of financial counselors within the emergency department," says Barnes. "They are available to work with the patients immediately, to assist in facilitating the payment process."

Patients who cannot make payments at the time of care are now given a letter stating the amount of the payment required, and a self-addressed paid envelope to send in their payment at a later date, says Barnes. "Our team also works with patients to develop extended payment options as needed," she says.

The financial counseling team deals with many challenges, says Wence, including compliance with the Emergency Medical Treatment and Labor Act, patient cooperation, clinical staff time with the patient, bed turnover, and identification of the patients they should see.

"However, the patient reactions are positive," says Wence. "Once the financial counselor explains to them that it's a free service, and that they are trying to help them with the expense of their medical visits, approximately 90% of patients are happy and cooperative."

Wence estimates that about 10% are "uncooperative from the start." Out of the 90% that are cooperative, she says that about 60% continue to be cooperative after they leave the ED and bring all the documentation needed to be approved for assistance.

"The good thing about the financial counselor seeing the patient in the ED and beginning the application process is that we will at least have a signed application," says Wence. This means that the hospital can collect some money from its charity care pool for uncooperative patients, she explains.

"They must have the initial signed application though for us to be eligible for that," notes Wence. "We instituted this process in October 2010 at our facilities. We have increased 'reimbursement' from the charity care program by $32,000 in one month for one hospital."

The hours of the financial counselor shift were determined by running statistics of the ED visits by insurance type and by time of day, says Wence. "Then, we determined the times of the day and days of the week with the most need," she explains.

Barnes notes that the best practice in the industry is to have a "discharge desk" in the emergency department and dedicated staff to collect out-of-pocket charges. "At this time, Lourdes does not have the space and staff to accommodate that practice," she says.

[For more information, contact:

Carole Helmandollar, Executive Director, Ambulatory Services, Children's National Medical Center, Washington, DC. Phone: (301) 572-3656. Fax: (301) 765-5650. E-mail:

Maria Wence, Corporate Director of Patient Access, Lourdes Health System, Camden, NJ. Phone: (856) 757-3676. Fax: (856) 968-2587. E-mail:]