At French Hospital Medical Center in San Luis Obispo, CA, the patient access department focuses on making cost of care more transparent to all patients. This did not work as well in the ED, since patients often left before staff even had the chance to complete a registration.

During a recent staff meeting, Director of Registration Diandra Jones showed clinical leaders the dismal financial clearance rate for patients who left without being registered. “I compared our collection percentages with our ‘missed signatures’ report for the ED,” Jones recalls.

The amount collected by staff was a tiny fraction of the estimated amount that could have been. “This shed light on an opportunity to enhance communication between patient access and clinical teams,” Jones explains.

Registrars and clinicians just were not connecting when it came to the patient’s status. On both sides, information was missed “simply because of logistics,” Jones notes. Two changes were made to improve financial clearance of ED patients:

Patient access staff, nurses, and clinical leaders were provided with radios. This low-tech method lets everyone communicate in real time wherever they are in the department. “The clinical team does not have to step away from the patient,” Jones observes.

On the clinical side, clinicians check with registrars to see if they need any more information if a patient is about to be discharged. Registrars let clinicians know if the patient’s insurance requires notice of admission.

ED registrars use an electronic tracking board to convey the patient’s status to clinicians. The clinical team now knows exactly when registration has been completed for the patient, or if a copay still needs to be collected. Fewer patients are discharged without a completed registration. More accounts are financially cleared, and fewer go to collection.

“We were able to improve collection efficiency for the ED by nearly 10%, and cut our missed signatures in half,” Jones reports.

In the ED, many team members (clinicians and registrars) interact with patients during long, stressful visits. After exhausted patients receive the all-clear to go home, they are not likely to stick around, notes Sarah Dresch, senior director of patient access at Ensemble Health Partners.

Hospitals are trying to shorten door-to-provider times. Lower-acuity patients are treated as “fast-track,” and discharged quickly. The registration teams might struggle to keep up.

“They are challenged with deciding which room visits to complete, based on length of stay, acuity, and not imposing on the clinical processes,” Dresch laments.

Registrars can check the electronic health record to see if a medical screening exam was completed, giving them the go-ahead to complete the registration and, hopefully, collect the copay.

Collection becomes exponentially more difficult without the patient’s contact information. “We have seen issues in which patients were discharged through alternative exits like the ambulance bays,” Dresch reports.

Patients bypassed the registration areas and left the facility without providing updated information or settling copays. To mitigate this ongoing problem, there needed to be much better collaboration between the patient access and clinical teams. This established a consistent workflow from patient arrival to discharge. “The physical patient flow throughout our ED was also evaluated,” Dresch says.

Now, discharged patients pass through a registration area on the way out of the hospital. This way, if clinicians release patients before registration was completed, patient access staff can quickly meet with the patients before they leave.

“If patient access teams were unable to connect with our ED patients prior to discharge, we would lose all collectability with these patients and strictly rely on collection services,” Dresch says.

At Woodsville, NH-based Cottage Hospital, ED patients leave without completing registration because the patient chooses not to wait for the registrar, or because registrars are not notified the patient was discharged. “It can be a timing issue, during the night, when patient access is closed and clinical staff did not complete the registration,” says Jennifer A. Florentine, director of patient access.

Registration is open from 6:00 a.m. to 9:00 p.m. After that, registrations are completed by the ED night technician, an LNA from the medical unit, or a house supervisor. At any time of day, patients arrive unidentified; many leave without registering. Only after the patient is medically screened can registrars ask for the copay.

Only about 5% of patients pay it. The rest receive a bill after the claim is processed. Most of those do not ever pay. “Once the patient leaves without paying, our ability to collect decreases,” Florentine laments.

Those patients receive a letter reminding them copay is owed. “Of those we send, we have about a 25% payment rate,” Florentine reports.