The most daunting challenge of collecting in the emergency department (ED) setting involves the simple fact that ill, injured, and tired patients just want to go home, as opposed to having a discussion about how much money they owe.

“Often, it’s all about logistics and routing the patient to a checkout desk when the patient is exiting,” says Jackie Shaw, regional director of patient access at University of Pittsburgh Medical Center (UPMC). Some patients already waited hours to see a physician. For many, the last thing they want is another stop on their way out the door. “We encouraged clinicians to direct patients to the checkout desk upon discharge,” says Shaw. “We shared our goals with them and pulled them in as part of the team.”

At the point of discharge, patient access staff validate the patient’s parking ticket, which saves them up to $25 in fees. Patty Devlin, UPMC’s director of self-pay, says, “That goodwill gesture has really gone a long way.”

If patient access staff collect before discharge, they need to do so only after the medical screening examination (MSE) is completed, as required by the Emergency Medical Treatment and Labor Act (EMTALA).

“We encourage the staff to collect at the bedside once the physician sees the patient and the MSE has been completed,” says Shaw. “We have the technology to support bedside collection.” Registrars monitor a tracking tool, which alerts them that the MSE has been completed.

A much larger percentage of collections occurs at the point of discharge, however. “Registration completion and accuracy is critical, so collecting at the bedside is a challenge for a busy department,” explains Shaw. “We are always looking to increase that percentage. It’s a continual area of focus.”

At the Cooper Health System in Camden, NJ, copays are collected after triage at the time of registration. If a patient is assigned a room, registration and copay collection are done at the bedside. All patients have an MSE completed before registration. Pamela Konowall, assistant director of health care access, says, “If registration takes place before a patient is assigned a room, the patient is registered using a desktop computer.”

At Davenport, IA-based Genesis Health System, all attempts to collect occur at the end of the ED visit.

“We have a designated checkout office at our three main campuses,” says Alissa Munson, registration supervisor. “Clinical staff escort the patients to that office, so that the registration process can be completed.” Staff then have the collections conversation with the patient.

Initially, clinical staff members were resistant to this process. “Nurses felt their job was completed once they discharged the patient and the patient left the examination room,” says Munson. Patient access leaders met with clinical leaders to set this new expectation. “As with every new process, it took time and persistence to get the process hardwired with the clinical staff,” says Munson.

Patient access leaders provided clinical staff with this suggested scripting: “Please stop at the checkout office. Registration will complete your discharge and get you on your way,” or “Please have a seat here (pointing to a small waiting area outside checkout). Registration will be right with you to finish your discharge.”

When ED collections first started, patient access staff members went into the patient’s room right after the MSE was completed. “The doctors alerted us when they felt they had met EMTALA,” says Munson.

However, after a few months of this process, hospital leaders decided they did not want the patient’s room to be associated with the collections process.

“So we moved that part of registration to the end of the visit,” says Munson. “We built checkout offices to accommodate the new process.”