People come to the ED sick, injured, or in severe pain. This is not an opportune time to ask someone for a $100 copay — or, worse, inform them they are responsible for the entire bill.

“It’s difficult to tell someone with no insurance that they are going to owe X amount of dollars and ask how they’d like to pay,” says Jennifer Sanchez, a senior patient access services representative in the ED at Phoenix-based Banner Health.

To help with this, revenue cycle leaders added two new frontend financial assistance tools. ED registrars offer patients payment plans based on the estimated amount due, or a Banner Health-branded credit card with a quick approval process. “It changed the thinking from ‘We have to collect’ to ‘I know how I can help this patient,’” Sanchez says.

For at least one patient, a financial conversation with a registrar was quite possibly a life-saver. The patient was anemic, had lost a lot of blood, and needed an immediate blood transfusion. The patient was just about to walk out of the ED and leave against medical advice because she did not have insurance. The physician assistant (PA) asked an ED registrar to speak to the anxious patient. Sanchez immediately came to the bedside and gave a price estimate for the ED visit (and another estimate for ED observation, since there was a possibility the woman would have to stay overnight).

Next, Sanchez went over all the options for help (charity care, financial assistance, and applying for the state’s Medicaid program). “I have never seen a patient more appreciative. She ended up staying,” Sanchez reports.

The patient did not think she would be approved for Medicaid because she was employed, but Sanchez encouraged her to apply anyway. Meanwhile, the patient set up a payment plan, with the understanding that it would be discontinued and payments refunded if Medicaid ended up covering the ED visit.

“Emergent medical care can quickly change a patient’s income status, making them eligible,” Sanchez explains. Patients’ status might change because income is lost due to extended hospitalization or a long recovery period.

The PA later told the registrar if the patient had left the ED, there was a good chance she would not have survived. “There are a lot of people who don’t seek the care they need because of financial issues or no insurance,” Sanchez says.

Remembering this makes it easier for registrars to perform their jobs, since the reality is many people already are worried about the bill, sometimes enough to leave without care. “When we see firsthand that it could literally be a matter of life or death, it makes it a little easier to start talking about money,” Sanchez says. “We know we have a solution for them.”

Recently, a family was about to leave the ED at Nemours/Alfred I. duPont Hospital for Children in Wilmington, DE. “They were unsure whether or not they were even allowed to be seen in the ED because they did not have insurance,” says Victoria Foster, a patient access service specialist in the ED.

Right away, Foster put the family at ease by stating, “No matter what, we will take care of your child. We have financial assistance programs that will help you. We’ll worry about the rest later.”

Foster held off on completing the registration until after the child had received care and the family had calmed down. “When we got to the financial responsibility section of the registration, I set the family up with a telephone appointment for financial services,” Foster says.

The family was surprised to hear there were assistance and uninsured discount programs, payment plans, and the possibility of Medicaid coverage. “This father was extremely grateful for everything we were able to do for him,” Foster recalls.

Now, patients can book their own financial services appointments online. If the family is at the ED during office hours, the family can get in touch right away. “However, we seem most successful with calling the family using an appointment time,” says Paula Jermyn, manager of family financial services at Nemours.

For the family, it is reassuring to know the financial aspects of the visit can be handled later. For financial advocates, it is easier to engage in a thorough discussion when emotions are not running high during the actual ED visit. “My team likes it because we know the family is expecting our call, and, typically, is responsive to our outreach,” Jermyn says.

The anxiety of not knowing the ED visit cost is enough to prompt some patients to consider leaving. At Children’s Hospital Colorado in Aurora, patient access has started providing cost estimates in the ED. “This will be a valuable tool to equip our patient access team. With the cost estimates, we expect to see an increase in overall collections,” says Suanne Kindel, operations manager for patient access and financial counseling.

All ED registrars participated in customer service training recently. The focus was empathy and compassion when collecting copays. “Our clinical team often informs patient access of possible challenges or sensitive situations prior to completing the registration,” Kindel says.

Abuse, trauma, or behavioral health issues are common. Registrars start by saying, “We are sorry you are in the emergency room. You are in good hands.”

Registrars do attempt to collect, but they do it with compassion. “We always say, ‘We can take care of your copay now, so you can focus on your child’s recovery,’” Kindel says.