When a patient at Salt Lake City-based Huntsman Cancer Hospital received an unexpected bill for $6,500, he filed a complaint with the hospital’s customer service and risk management team. “The hospital bill was way more than what he was initially quoted,” says Junko I. Fowles, CHAA, supervisor of patient access and financial counseling in the division of revenue cycle support services.

The patient had been quoted $250 for a new patient pathology over-read, as per the hospital’s policy. “And that was exactly what was ordered by an attending physician,” Fowles says. It turned out that the pathologist who interpreted the materials had ordered molecular testing to confirm the diagnosis. “This was happening behind the scenes,” Fowles explains. “Nobody, including the ordering physician’s office or financial counselors, was notified of such expensive tests being ordered.”

The patient was not made aware the testing was ordered, either. “He certainly had no idea what his out of pocket would have been. Otherwise, he would not have consented,” Fowles notes.

It took more than two weeks for the department to figure out the root cause of the issue. First, the department contacted outpatient coding to see if there was an incorrect charge posting. Then, the department contacted the claims follow-up team, the laboratory, financial counseling, the referring physician’s office, the attending physician’s office, and pathology.

“The change we’ve made from this experience is to have the pathologist team notify us before ordering expensive molecular testing,” Fowles says. This way, the patient learns about possible high out-of-pocket costs.

Revenue cycle leaders are looking into automating the process. Any molecular testing orders placed in the system would flag the attending physician’s office, financial counselors, and the prior authorization team.

The team still had to address the individual patient’s concern. “We contacted the patient and explained what had happened,” Fowles says. Staff told the patient that since these were billable charges, the hospital still would bill his insurance, but would adjust his liability accordingly.

Another common complaint at Huntsman also involves surprise bills. Some patients learned that their insurance was out of network with the hospital only after the completion of a service. This scenario happens more often because of payers’ “narrow” networks. “It’s becoming such a challenge to know what plans and payers are accepted by our facility and providers,” Fowles says.

Many out-of-network patients cannot afford their out-of-pocket costs. “It would end up in hospital charity write-offs and bad debt,” Fowles notes. To improve communication with patients and reduce write-off amounts, the department took these steps:

  • The department created a work queue to capture out-of-network plans;
  • Financial counselors notify patients that they’re out of network prior to the date of service;
  • Supervisors provide ongoing training to front-end staff on how to identify out-of-network plans. “We share payer updates from the contracting team with the front-end users,” Fowles adds.


  • Junko I. Fowles, CHAA, Division of Revenue Cycle Support Services, Huntsman Cancer Hospital, Salt Lake City. Phone: (801) 587-4036. Fax: (801) 587-8269. Email: Junko.fowles@hsc.utah.edu.