A growing emphasis on upfront collections occasionally results in dissatisfied patients. Patient access leaders can take the following steps to mitigate collection-related complaints.

  • Support registrars if patients do complain.
  • Start financial discussions as early as possible in the process.
  • Give registrars scripting so they can be confident in asking for money.

“They want us to collect, but when a complaint goes to the CFO or CEO they don’t have our backs.”

Registrars might not admit they feel this way, but many have expressed this sentiment to Brandi Nash, a revenue cycle consultant at Warbird Consulting Partners in Atlanta, GA.

“We are holding them accountable, but then we, as leaders, are not standing up for them,” says Nash.

Upfront collections do not need to conflict with customer service, however. “The expectation needs to be across the board at all levels in your facility,” says Nash. “If you receive a service, the expectation will be that payment will be discussed at the time of service.”

Problems come if registrars are expected to collect, but aren’t supported if patients complain about it. “This is a huge deal breaker for your front-end associates,” says Nash.

An uptick of complaints about collections could signal a bigger problem than just one interaction that went wrong.

“Some clients are overly aggressive in the patient access area, due to the demands coming from the C-Suite,” says Nash. “Finding the right balance is difficult.”

Patient access leaders should hold registrars accountable for collecting. “But we don’t want to create associates who are only focused on the money and lose sight of patient care,” says Nash.

Having solid scripting for the collections conversation is helpful. “It decreases the chances of the associate going ‘rogue,’” Nash explains. “The associate has less opportunity to be overly aggressive in demanding payment.”

Even if a registrar is following guidelines and scripting to the letter, there are still times when he or she will be unable to collect. Nash goes by the “80-20” rule for collections: “As leaders, we have to accept the 20% of not collecting, but do a robust job on collecting the 80%.”

Start Conversation Early

Joyelle T. Chrysostom, manager of financial clearance operations at Albany Medical Center, says registrars hear complaints about collections on a daily basis. Common comments are “I’ve never been asked to pay before,” and “It’s poor customer service to collect when someone is sick.”

“The key is to communicate any financial responsibility to patients early in the revenue cycle,” says Chrysostom. For instance, financial conversations begin while the patient is still in the ED for patients being admitted.

“We advise the patient that he or she may have a copay or deductible,” says Chrysostom. If the patient is informed of this before going to the floor, he or she is less likely to send the credit card home with a family member. Sometimes, the mere mention of a copay spurs the patient or family to call the insurance company to confirm their financial responsibility.

“It is critical to let patients know that we are here to service them, and that options are available,” says Chrysostom.

These include payment plans, Medicaid screening, or financial aid. “We also offer to collect over the phone from a family member on behalf of the patient,” says Chrysostom.

Projecting Confidence

Despite the growing practice of point-of-service collection, many patients still say, “I never had to pay upfront before.” Registrars at Shasta Regional Medical Center in Redding, CA give this response: “We realize you may have not been asked in the past. But based on your benefits, our department is now required to collect upfront.”

“If patients express they can’t make a payment, we ask if they can pay anything toward the deductible. If not, we move on and still provide exceptional customer service,” says Kim Rice, director of patient access. Rice says patient access staff need to understand these two things:

  • The overall revenue cycle process;
  • The advantages of collecting upfront — both for the patient and the organization.

Patient access staff need to understand what they are asking for and why. “When clerks can answer questions, it provides that extra confidence the patient needs to see,” says Rice.

The opposite is true if the registrar doesn’t know why he or she is asking for money or seems inexperienced.

“The patient can usually get out of paying easily — and it doesn’t confirm their sense of confidence in the facility as a whole,” says Rice.

Patients Want to Know

A little bit of education during registration or preregistration helps patients understand why upfront collections happen more today than in the past.

“In my experience, when you explain to patients what you are doing, they are open to your explanation,” says Rice.

When patients do not understand why staff are collecting or their questions are not answered, they are more inclined to complain.

“It is important that the staff know to ask for assistance if they sense a problem with the patient,” says Rice. This prevents things from escalating to the point where the patient feels the need to complain to someone.

“People, in general, want to know what they are paying for,” says Rice. Scripting and thorough explanations are needed.

“We let the patient know there is an amount due based on their insurance benefit, and what the payment is for,” says Rice.

Many patients ask what their out-of-pocket costs will be. This is not always an easy question to answer. “We are limited to the tools we have to give a specific amount,” says Rice. “Sometimes, management must step in and provide extra guidance.”

One patient wanted to know a definite amount. He didn’t believe the registrar, who told him only an estimate was possible. “I met with the patient and explained that we really don’t know how the insurance would process the claim,” says Rice.

Rice then told the patient what was known for certain about his out-of-pocket costs. To give a good estimate, it was necessary to know the type of service, the benefits for that service, if the deductible had been met, and whether the patient had any other health visits in the calendar year that would have gone toward the maximum benefits of his coverage.

“Once I explained the details, the patient was satisfied and continued with the service,” says Rice.


  • Joyelle T. Chrysostom, Manager, Financial Clearance Operations. Albany (NY) Medical Center. Email: chrysoj@mail.amc.edu.
  • Brandi Nash, Warbird Consulting Partners, Atlanta, GA. Email: bnash@warbirdcp.com.
  • Kim Rice, MHA, Director of Patient Access and Communications, Shasta Regional Medical Center, Redding, CA. Phone: (530) 229-2944. Fax: (530) 244-5185. Email: krice@primehealthcare.com.