Increasingly, ED clinicians field questions from patients regarding the cost of care. At NYU Langone Medical Center, physicians refer patients directly to financial counselors.

  • Clinicians were concerned that patients might leave without treatment because of financial concerns.
  • Patient access worked with IT to develop a process for ED physicians to refer patients directly to financial counselors.
  • Financial counselors contact patients on the next business day.

Patients asking about cost sounds like a simple question, but it’s usually impossible for ED clinicians to answer.

“It is one of the most dreaded questions on the front line of an ED,” says Nicholas Gavin, MD, assistant professor in the department of medicine at NYU Langone Medical Center and chief of service in the ED at NYU Lutheran Medical Center.

Some patients admitted for observation expressed concerns because they’d seen media coverage warning of inappropriate billing practices at other institutions.

“Patients were concerned that observation services would lead to more out-of-pocket expenses,” Gavin recalls.

Others worried because of their high-deductible insurance plans.

“As patients’ out-of-pocket expenses go up, they are rightly going to be asking more questions about the financial impact of their healthcare choices,” Gavin explains.

ED patients ask these questions frequently, reports Sean McAleer, senior director of revenue cycle operations in the Ronald O. Perelman Department of Emergency Medicine at NYU Langone:

  • How much will the entire ED visit cost?
  • How do I know if the ED provider accepts my insurance or is in network?
  • Can I choose an ED provider that is in network?
  • Does my copay cover every service?
  • How much does an X-ray cost?
  • If I pay the self-pay amount, is this the entire cost of the ED visit?
  • How much will it cost if I get admitted?
  • Do I have to pay now?
  • What happens if I cannot afford to pay?

ED patients are made aware of financial assistance in many ways. The department posts conspicuous signage and offers patients a pamphlet with answers to frequently asked questions. The information also is on ED discharge forms.

In addition, McAleer adds, “registrars are trained to refer patients to a financial counselor if a patient expresses a financial hardship or an inability to pay.”

Even so, many patients are still unaware that financial assistance is available. Many ED patients don’t read signs or pamphlets or interact with registrars because of severe illness or injury.

When patients confided their anxiety about cost to their ED clinicians, McAleer says, “there was no outlet for the physician to direct those concerns.”

Patient access worked with IT to develop a process for ED physicians to refer patients directly to financial counselors. The requests go into a special work list, alerting the counselor that the referral came from the ED.

“They know that a patient confided in their physician with a concern about their bill and to broach the financial aspect of their treatment with utmost sensitivity,” McAleer explains.

Patients’ increasing worries about cost of ED care was the motivation for this change.

“While our system moves toward more price transparency, we need to facilitate frontline providers’ comfort with financial safety nets for patients,” says Gavin, lead author of a recent paper that outlined the ED’s new process.1

If patients ask about cost of care, ED providers respond: “I’m not sure, but I’m going to ask our financial counseling team to reach out to you on the next business day. We are going to do what is best for your health, and work together on financial issues tomorrow.”

Referring ED patients to financial counselors, says Gavin, “allows our providers to put these questions in the hands of experts within our system.”

Before the new process was in place, ED providers worried that some patients would leave against medical advice, or before their treatment was completed, because of a perception that care was going to be unaffordable.

“With all the burdens on today’s frontline ED providers, we hope to alleviate some with this initiative,” Gavin says.


  1. Gavin N, McAleer S, Asfour L, et al. Bridging the gap: Financial counseling in the ED. Healthcare Financial Management 2016;70:66-70.