Upfront collections are a major focus for revenue cycle departments, with a strong emphasis on early financial clearance of accounts. Widespread unemployment and coverage loss has altered that for the foreseeable future, at least to some extent.

At North Mississippi Health Services in Tupelo, patient access staff used to set a clear expectation of payment up front. “The general message we convey now is, ‘Whatever you can pay, we need for you to pay,’” says Carol Plato, vice president of revenue cycle. Registrars are seeing these groups of patients:

Some people want to pay up front and be done with it. Registrars do not wait anymore for people to ask for discounts. “We tell everyone up front, ‘If you pay now, we’ll give you a discount,’” Plato reports.

If patients ask for a bigger discount than is allowed, staff keep it simple. “We explain that we cannot go outside our policy, and we are doing the best we can,” Plato says.

The discount offered depends on the total. A bigger balance means a better discount. Discounts typically range from 5% to 20%. “It saves us statement costs and collection costs,” Plato notes. “If the account got to a bad debt status, we would offer a discount anyway.”

Many people are out of work, and cannot afford to pay anything. Ordinarily, elective services would be rescheduled for this group. “We’re taking everybody right now. We are not turning patients away like we might in normal times,” Plato explains.

Charity care dollars are expected to increase significantly. Many patients say right from the beginning they cannot pay. “We get the process started,” Plato says. “We note on the account that the patient appeared to need charity.”

Registrars can always come up with some kind of solution as long as care is planned, even for high-dollar accounts. “The hardest group is when care is unplanned,” Plato says. “They don’t realize how expensive it is, and are unprepared to pay.”

For patients presenting to the emergency department, the usual process is to collect at least copays. “Now, we ask — but we’re not pressing it,” Plato adds.

Some people cannot pay in full, but do not qualify for charity care, either. For this group, payment plans usually are the best option. The department changed the way those are handled. Previously, the hospital paid a small percentage of the account balance to the vendor. “We only get 30 to 40 cents on every dollar of self-pay balances to begin with,” Plato says.

That is because the odds of collecting after service (instead of at the time of service) drop dramatically. “In our situation, we have only about a 30% chance of collecting after the patient has received a statement,” Plato says.

Accounts involving emergent care or large balances were the hardest to collect. To offset all the lost revenue, Plato’s department recently switched to a different model. The vendor still sets up the payment plan, but patients pay a small monthly fee to continue with it. If the patient is paying $100 a month with a $4 monthly fee, the hospital receives $100 a month, and the vendor receives $4.

The hospital (eventually) receives 100% of the balance due. The vendor receives a small profit on each payment made, after statement and processing fees are covered. The patient can make small payments over a long period.

“Plans differ based on balance size, and will change if new balances are added to it,” Plato says. The minimum payment accepted is $25, but plans go as long as necessary. “We find that patients pay off the balances sooner when they have a small fee associated with their plan,” Plato observes.

However, when the account is resolved (with charity care, payment plans, or discounts), ideally, it happens up front. “Resources on the front end reduce denials, errors, and rebilling on the back end,” Plato notes.

That means the central business office spends much less time chasing all the problematic accounts. “The more we get done at the front end, the less FTEs [full-time equivalents] we need on the back end,” Plato says.