ED registrars should never discuss or ask for payment prior to meeting EMTALA requirements, says Maureen Bottom, patient access director at Texas Health Resources.

“In no way do we want to interfere with emergency or stabilizing medical care, or give a perception that ability to pay comes before their health,” Bottom says.

The hospital’s EHR tells registrars when it is OK to obtain consents and educate the patient about insurance coverage findings. Avoiding finances entirely is not realistic and is in no one’s best interest, Bottom says. The hospital needs payment, and patients want to avoid surprise bills. “Surprise billing is a hot topic for consumers, so not talking about insurance benefits can be a bigger problem,” Bottom notes.

Many patients have heard horror stories about astronomical bills for ED visits. Some patients arrive already worried about what insurance will cover and bring up the topic themselves. “Patients absolutely want to know,” Bottom says. An unexpected, confusing hospital bill coming weeks or months after the ED visit devastates patient satisfaction scores. “It sometimes sours the patient’s overall experience, even when the healthcare experience is exceptional,” Bottom says.

Patients have a right to make choices on where they receive care. However, as a Level II Trauma Center, Texas Health Fort Worth receives some patients with needs that cannot be met anywhere elsewhere in the community. Giving people the information they need to make informed financial decisions, while encouraging them to get care they really need, is quite a balancing act.

“[Registrars] work hard to share any pertinent information when the situation is right,” Bottom says. “But at the same time, we always respect the healthcare needs of the patient.”

“Is this hospital in network with my insurance?” This is one of the most common questions people ask ED registrars.

“Helping the patient understand what this means and how it impacts them is critical,” Bottom says. Usually, patients are visibly relieved to find out their hospital is in network. Bearing this good news is a jumping-off point to talk about what is not covered.

“It helps to promote trust and transparency about pricing and payment expectations,” Bottom says. “Sometimes, that conversation leads to learning about alternate healthcare resource options.”

However, registrars are careful not to sound like they are discouraging the patient from seeking care in the ED. “Unhappy patients or family who feel their right to access has been obstructed may complain to CMS,” Bottom cautions. Patient access keep patients informed without implying they should go elsewhere and collect balances owed — yet not too aggressively.

“We have found good success collecting payment in the ED,” Bottom reports. “But we continually work with our staff to maintain the right balance.”

Registrars use a matter-of-fact, conversational tone. They also pick up on signs that it is just not the right time to talk about money, such as when a physician is reviewing test results.

“We coach our team to be aware of activity in the room and to always remain sensitive for the situation at hand,” Bottom explains.

Assuming the timing is right, registrars say something like this: “Ms. Smith, I verified your insurance with (name of plan), and it’s active for today’s ER visit. We are an in-network provider for (name of plan), and your plan with (name of patient’s employer) covers (coverage details). Your deposit for today is ($ ___).”

Pressing someone to take care of the balance right away is discouraged. “Pushing too hard for payment is off-putting and could appear insensitive,” Bottom says. To bring this message home, employee incentives are based on patient satisfaction, not how much they collect.

Overall, the ED registration encounter is meant to offer patients “a total package of service and education,” Bottom says. Staff do not just ask for payment; they also confirm the patient’s identity and demographic information and obtain consent forms. While taking care of these routine tasks, registrars establish a rapport with the patient.

“Our team’s goal is to empower patients with billing and payment information vs. wearing a collector’s hat,” says Bottom, noting that the collection part of the conversation is consistent. “We always talk about it, we always ask, and we aren’t shy about the conversation.”