Rising deductibles and lack of information on out-of-pocket costs make emergency department collections difficult, but patient access departments are succeeding with tools and training. Collections at Genesis Health System nearly doubled with a payment estimate tool, and collections rose by 10% at Cooper Health System because staff ask consistently.

• Require registrars to ask for payment at every visit.

• Set the expectation for clinical staff to direct patients to the checkout area.

• Offer a prompt pay discount to patients who pay in full that day.


Emergency department (ED) registrars at Davenport, IA-based Genesis Health System’s five hospitals collected $190,000 in Fiscal Year 2014. Collections topped $368,000 the following year, after a payment estimating tool was implemented.

Previously, patient access didn’t give estimates at all. “We were just collecting copays. If patients did not have copays, we were asking for $100 deposits,” says registration supervisor Alissa Munson. The tool is the Patient Payment Estimator from Passport Health in Franklin, TN.

ED collections increased 10% last year at Cooper Health System in Camden, NJ, with the simplest of changes: Staff ask for payment consistently. Pamela Konowall, assistant director of health care access, says, “After being trained in how to make ‘the ask’ for each and every visit, employees were amazed at the simplicity of the process.”

At University of Pittsburgh Medical Center (UPMC), collections are tracked by individual staff members. “This allows us to work with low performers to coach them,” says Jackie Shaw, regional director of patient access at UPMC.

Patient access mandates frequent training on collections, based on real-world scenarios, to allow staff members to become comfortable with the process of asking for payment. “We engage staff in every aspect of payment collections by sharing personalized metrics on a daily, weekly, and monthly basis, and recognizing year-to-year performance,” says Shaw. More than half of UPMC facilities are averaging a 46% or greater collection rate for total copayments.

Initially, many of Cooper Health’s registrars were reluctant collectors. “In short, they were hesitant to ask,” says Konowall. First, patient access leaders re-trained all registration staff in insurance eligibility and patient liability. “The training department tested employees on their interpretation of eligibility responses and identifying the amount of the copay due for the day’s visit,” she explains.

Next, patient access trainers created an online module. This module covers scripting on how to ask for a copay, how to explain what a copay means, what the benefits are for paying a copay at the time of service, and how to respond to questions patients might ask. (See scripting used by patient access staff in this issue.) “If a patient can’t pay the full copay amount, we encourage the patient to make a partial payment,” adds Konowall.

Instead of asking patients if they wanted to pay their copay, staff ask how they will make the payment, by cash, check, or credit card. Payment software also was implemented. “As an additional enhancement to increase cash collection in 2015, credit card swipes were added to the registrars’ desktops and ‘workshops on wheels,’” known as WOWs, says Konowall.

Previously, employees had to go to a stationary computer or enter the credit card information manually. Adding the swipes eliminated the risk of typing a credit card number inaccurately. “Staff is now comfortable with identifying copays, asking patients for payment, and processing the payment,” Konowall reports.

More out-of-pocket

At UPMC, “collections in the ED have always been a challenge,” says Shaw. “We continue to improve, even as copays continue to increase.” Rising copay amounts are placing a greater financial responsibility on the patient. “Those amounts can be a hardship for patients,” says Shaw. If patients express an inability to pay, UPMC’s patient access staff members do the following:

  • determine if the patients have a flexible spending account or health reimbursement account to help with the costs;
  • document reasons given for patients being unprepared to pay;
  • ask for a partial payment if the patients say they can’t pay the full balance;
  • refer the patients to a financial counselor to discuss additional options for assistance.

It often is difficult to provide accurate estimates for patients in the ED setting, notes Patty Devlin, UPMC’s director of self-pay. UPMC’s patient access staff members collect outstanding balances on prior accounts from ED patients. However, they don’t collect deductibles or coinsurance for the ED visit.

“We may know the deductible is $5,000, but we don’t know how much of it is met,” says Devlin. “That information is not readily available in the ED.”

Genesis Health System’s patient access leaders created templates for each of the five acuity levels used in its EDs. “Based on those templates, and information provided by the patient’s insurance companies, we are able to provide an estimated amount due for that visit,” says Munson.

Patient access staff at Genesis offer an upfront prompt pay discount if patients agree to pay in full that day. Patients receive a 10% discount, and self-pay patients receive a 40% discount. “Offering the discounts has been a great tool to get those who would generally wait to pay to, instead, pay upfront,” says Munson. For fiscal year 2015, the department gave patients more than $180,000 in discounts.

Registrars also offer payroll deductions to hospital employees and their families. “Staff that are seen in the EDs really like having the option to make payments over a period of time instead of paying the full amount upfront,” says Munson. (See related story on bedside collection versus collecting at patient discharge in this issue.)