At Albany (NY) Medical Center, a bedside point-of-service collections initiative in the ED began in 2018. It started rocky. “We started with incentives for staff,” says Karen Gardner, manager of access services for the ED. Registrars who agreed to collect were given longer lunch breaks or were allowed to pick their daily assignments, such as bedside registration or answering incoming calls.

This worked well — for a few months. Soon, the department found that the incentives “become a nightmare to manage,” Gardner laments. “We had all staff collecting, which was great.” But providing 45-minute lunches for up to 14 people per shift proved impossible to maintain. The incentives were taken away, and it did not take long for collections to plunge to near zero. “Our mistake was not having a plan in place to hold staff accountable,” Gardner reports.

A few months later, the department set a new collection goal of 50% of potential outpatient dollars. At the time, registrars were collecting anywhere from 19% to 24% of this amount. “We needed to find a way to hold staff accountable, in real time, to the goal,” Gardner says.

First, leaders tried to motivate staff by keeping them in the loop on how the department was performing overall. Each week, staff received a report detailing the dollar amount that was collected compared to the potential amount that could have been collected. The report also tracked registrar mistakes. These included insurance errors, eligibility errors, third-party liability errors, and amount-owed errors. Managers noticed some mistakes in Coordination of Benefits rules, which apply when someone presents with both Medicare and another kind of insurance.

A common mistake is incorrectly billing Medicare as the primary insurance instead of an HMO. In some cases, a patient’s amount owed was incorrectly listed as zero. This meant that no one collected at the bedside. Also, the copay collection letter was not sent the next day since it appeared the patient owed nothing. “When we reviewed the encounter on the next day, we would provide education on reading our eligibility response,” Gardner says. Sometimes, staff struggled to determine what the patient owed. Also, they were unclear as to whether there was third-party liability.

To clear up confusion, staff were divided into groups, led by one of four supervisors. Each newly hired employee is placed in an “onboarding” group for the first six months. The others are assigned based on their primary shift, with groups ranging from six to 11 employees. Each supervisor was charged with educating the entire group on common errors, the Coordination of Benefits rules, how to determine the patient’s financial responsibility, and encouraging staff to collect bedside.

“Our previous collection process was waiting for patients to present to an office after services were completed,” Gardner says. This was not very effective.

Scripting, role-playing, and observation were used. “Getting over their fear of asking for money was the biggest hurdle,” Gardner recalls.

Equipment was another frustrating obstacle. “Our wireless credit card machines are not the most reliable,” Gardner says. The IT and cash management teams are working on the problem. For now, staff use a wired credit card machine, which is not ideal because payments cannot be processed in-room.

Staff were emailed the metric on the department’s performance every week. “There was little improvement,” Gardner says. Things changed quickly when the department started publicly posting the same information, but this time about individual staff members. Every registrar’s status on how much they collected and how this compared to the potential that could have been collected is posted by color. Employees who collect from 0% to 15% get a red card, 16% to 35% get orange, 36% to 49% get yellow, and more than 50% get green.

Currently, the department has almost reached its target. “We are running at 48% of potential dollars collected for the pediatric and adult EDs,” Gardner reports. “Staff are responding to peer-to-peer competition.”

For now, at least, patient access is not planning any changes to this successful process. Every Tuesday, associates are called out on the collection board if they improve from where they were the week before, or if they reach the level of green. Staff members stuck at the “red” level are asked what is keeping them from collecting. Associates who improved enough to change to a higher color level are asked how they did it. Any associate who earns four green ratings in a calendar month receives a gift card and praise at a staff meeting. “It has been a very dynamic and engaging process for the team,” Gardner says.

Albany Medical Center’s registrars have experienced success collecting, but they do so with caution. All receive extensive EMTALA training, starting at their orientation. Skills are reviewed annually.

To avoid EMTALA issues, an attending physician at the ED’s walk-in entrance screens patients almost immediately. Once EMTALA requirements are met, staff complete the registration and request payment. This is the script: “You have a ($$) financial responsibility for today’s services. We accept credit card, cash, or check. How will you be paying for your services today?”

“Associates are trained to be direct and confident in their words,” Gardner says. “Consistency brings hardwired behavior, and patients respond to that.” Registrars are instructed not to demand payment or threaten to withhold services if someone cannot pay. Patients rarely leave the ED due to concerns about their financial obligations, Gardner notes. “If a patient gives any indication that they may leave because of an inability to pay at the time of service, we explain they have options.”

Registrars explain that partial payments are accepted, or a copay letter can be mailed the next day. Patients can call the department to make a payment, or they can be billed later. “We can also direct them to our patient assistance unit for financial aid screening,” Gardner says.