Executive Summary

With a preservice financial clearance process, Cox Health increased annual point-of-service collections to $1.4 million from $800,000; Texas Health Resources’ collections rose from $8 million to $11 million.

  • Patients meet one-on-one with a financial counselor.
  • Doctors’ offices set up meetings with financial counselors electronically.
  • All hospitals within a system use the same policies for financial clearance.
  • Tools including payers’ contracted amounts offer better estimates.

Upfront collections at Springfield, MO-based CoxHealth totaled about $800,000 in 2015, but soared to $1.4 million the following year. “We are on track to surpass that number for 2017,” reports patient access supervisor Rebecka Sandy, CHAA, CHAM.

The department’s secret weapon is a new preservice financial clearance process. “We have strived to automate our workflow with real-time data,” says Sandy. The new process includes the following:

  • medical necessity checks;
  • benefit verification;
  • estimate preparation;
  • patient education on out-of-pocket responsibility and payment options.

Several years ago, the department added a financial clearance process for uninsured patients. “This consisted of a one-on-one meeting with our counselors to educate the patients on their options,” says Sandy.

This is done for every uninsured patient scheduled for a non-emergent outpatient test or procedure. If patients fall into the hospital’s charity policy guidelines, financial assistance is offered. “Payment options can be provided, and may consist of a no-interest bank loan,” says Sandy.

Patient access recently automated these parts of the process:

  • Referrals to financial counselors are done electronically.

Previously, if patients needed help with their out-of-pocket costs, patient access emailed financial counselors to set up a referral. “This was not optimal, because referrals could easily be overlooked,” explains Sandy.

Now an automated process is used. “Any doctor’s office or patient can easily make an appointment with a financial counselor, using a link to the scheduling system,” says Sandy.

Self-scheduling allows patients to pick a time that’s most convenient for them. It places the appointment automatically on the financial counselor’s calendar.

With this method, “nothing is overlooked, and productivity for the counselors is easily tracked,” says Sandy.

  • Estimates are done using an automated tool.

Preservice employees used to have to call insurance companies or visit their websites every time they wanted to obtain benefit information. This was very time-consuming and, often, inaccurate. “Creating an accurate estimate was very challenging because of limited access to contracted rates and pricing,” says Sandy.

The department recently implemented an automated tool (Availity, based in Jacksonville, FL) to run insurance eligibility and create estimates. “All of our contracts and pricing are built in. It is quick and convenient for the registrar,” says Sandy.

Some self-pay patients are surprised to learn they are eligible for coverage, reducing charity dollars. “Securing insurance coverage for some individuals increases revenue for the hospital,” says Sandy.

Consistent Practices

The financial clearance process at all of Arlington-based Texas Health Resources’ 24 hospitals was revamped recently. High-deductible plans and soaring out-of-pocket costs were the main drivers of this big change.

“With changes to insurance plans, the days of owing a simple copay or small coinsurance amounts are long gone,” says pre-access director Alyssa McDonnold, CHAM.

Patient access leaders looked closely at the following three metrics:

1. Patient satisfaction scores.

2. The number of calls patients received about their accounts when an upfront deposit was due.

Before, there were two separate steps: preregistration and financial clearance. This meant patients were getting too many phone calls.

Patients usually were called one to three times before preregistration was completed — and then got several more calls for the financial clearance process.

“The new process has cut it to under two phone calls,” says McDonnold. Some patients get no call at all, since incoming calls are now transferred directly to the scheduling departments.

“In these cases, we can have a one-call resolution,” says McDonnold. “The patient doesn’t get outbound calls, and the center doesn’t take up resources making them.” Other patients get a single call, with preregistration and the full financial clearance conversation done at the same time.

3. The time between appointments being scheduled to the account being financially cleared for service.

“So many phone calls to the patient delayed accounts from being financially cleared,” explains McDonnold.

Based on these three important metrics, says McDonnold, “we knew that we had a need for improvement.”

The previous process was very inefficient. First, the Pre-Access Service Center determined that the patient could not meet minimum deposit requirements. Next, the account was forwarded to financial clearance for review and follow-up.

“This was creating inconsistency with financial clearance practices across the system,” says McDonnold.

A centralized approach to financial clearance was implemented in 2016. All hospitals now use the same process.

“We took the financial policy and added detailed specifics on what would be done at each stage depending upon the patient’s financial situation,” says McDonnold. This ensures all cases are financially cleared before the date of service. As a result, upfront collections increased from $8.3 million in 2015 to $11.6 million the following year.

“The financial screening process includes a review of the case by the ordering physician for medical urgency, continuum of care review, family poverty level review, Medicaid referral, and outstanding balances that the patient owes,” says McDonnold.

Patients appreciate getting fewer phone calls. Before the new process was implemented, satisfaction scores were stalled at 67%, but have since risen to 88%.

“There are fewer outbound phone calls, and scripted, detailed explanations are given to patients so they are aware of all their options,” says McDonnold. (See sample scripting used by the department in this issue.)

Registrars at Arlington-based Texas Health Resources’ 24 hospitals use the following scripting when having financial discussions with patients.

  • For self-pay patients:

“Based on the information you have provided today, the estimated cost for this procedure is ($). We give all self-pay patients a discount, which brings your estimate to ($). Please keep in mind that this is only an estimated calculation, and could change depending on the services your physician performs.”

  • For insured patients:

“According to an online check of your insurance benefits, the deposit amount due for this service is ($). Please keep in mind that this is only a deposit calculation based on your benefits from the automated system. Once the insurance company processes the claim, you may be billed for any additional amounts that you owe. They may not pay for all or part of your services, based on your benefits at that time. I must also advise you that this deposit calculation includes the hospital bill only. You will be billed separately for other physician services.”


  • Alyssa McDonnold, CHAM, Pre-Access Director, Patient Access Intake Center/Strategic Revenue Services, Texas Health Resources, Arlington, TX. Phone: (682) 236-1710. Email: AlyssaMcDonnold@texashealth.org.
  • Rebecka Sandy, CHAA, CHAM, Supervisor, Patient Access, CoxHealth, Springfield, MO. Phone: (417) 335-7249. Email: