Should you decentralize to increase collections?

Hospital collects almost $700,000

When administrators at Shands at the University of Florida in Gainesville asked his opinion about how they could increase point-of-service (POS) collections, Tim Carney, manager of outpatient financial arrangements, told them in no uncertain terms that decentralization was the key.

"I said, 'People are not going to come to a centralized area to give us money. We need to be in the ancillaries, in the lab, in pulmonary, and in radiology.'"

However, decentralizing means adding more staff. Carney asked to double the size of his 25-person department. "I had 25 people in the room calling people and creating accounts and doing it all over the phone, but the problem was we were only collecting $1 million a year in POS," says Carney. Carney asked for a total of 54 FTEs, but his request was denied. Instead, administration asked him where he thought the maximum opportunity was. He told them it was in the magnetic resonance imaging (MRI) area.

"So they gave me six people, and I collected almost $700,000. So then they said, 'OK, it's working,'" says Carney. "Today, I have double the staff, but we went from collecting $1 million to $6.8 million last year in POS."

The only way you are going to collect from a patient is to "be there," says Carney. "If the supermarket let you go out the door with your groceries without paying, would you pay? No — before you leave, you go through collections."

Patient access staff at Shands have made dramatic gains, although they don't always collect the full amount due from every single person. "If the deductible is $200 and the patient says, 'I can't afford that; can I give $100?' You know what? We take it. We're a teaching institution and not hardcore," says Carney. "But we only got that $100 because there was someone there to ask."

If the copay is not collected at that point, then the billing department sends out a bill. "And you can survey billing departments across the nation and see what they're getting, but what I always read is somewhere between 15 and 25 cents on the dollar," says Carney. "So if the copay gets by us, that's all the hospital is going to get."

St. Joseph Medical Center in Towson, MD, currently has a central billing office. "But we do all of the front-end pieces back here. So in order to reduce the cost of an agency to collect their copay, we are training our front-end staff to do whatever they can to get it," says Cathy Foster, director of the hospital's revenue cycle.

However, the hospital is now switching to a central registration area where all outpatient ancillary areas will be registered. "Before, patients were registered in the clinical areas, but they didn't want their staff dealing with copays and insurance authorization," Foster says, adding that she expects the new process to decrease precertification denials.

Previously, nuclear medicine and cardiology patients were registered by staff in those areas, but they will now be registered in a centralized area. "This will allow for us to have more standardized procedures," Foster says.

All of the registrars in the centralized area will be trained by an access trainer, the same person who trains all of the hospital's registrars, financial counselors, and schedulers.

"Our trainer's biggest challenge is the insurance piece. The patient may have Aetna insurance, which has an HMO and also a standard indemnity plan. The registrar sees all these cards, and it's very complicated for them to know which insurance pneumonic to pull," says Foster. "Our trainer does very in-depth training with competencies that she puts them through before she lets them go out and do their own thing." The trainer also mentors registrars for their first 90 days of employment.

Two ancillary areas have given staffing resources to patient access, which meant that no additional FTEs were needed. "They had a registrar in their area, but really, they had other things to do," Foster says. "But now they have tightened up some things, and that left them with a resource they can give us."

As compliance becomes increasingly complex, dedicated staff are needed as opposed to clinical staff who also have to worry about patient care, says Foster. "We used to have a single compliance person here, but we are now expanding. With all the minute details that we have to pay attention to now, compliance is becoming a bigger and bigger thing," she says. "You have to scrutinize everything so much."

[For more information, contact:

  • Antionette Anderson, CHAA, CHAM, director of patient access & centralized scheduling, Skaggs Community Health Center, P.O. Box 650, Branson, MO 65616. Phone: (417) 335-7701. E-mail: AGAnderson@Skaggs.Net.
  • Tim Carney, manager, outpatient financial arrangements, Shands at the University of Florida, 1600 SW Archer Road, Gainesville FL 32610. Phone: (352) 265-3673. E-mail:
  • Anna Dapelo-Garcia, director, patient admitting services, Stanford Hospital and Clinics, 300 Pasteur Drive, Room H1105B, M/C 5224, Stanford, CA 94305. Phone: (650) 723-9292. E-mail:
  • Cathy Foster, director, revenue cycle, St. Joseph Medical Center, 7601 Osler Drive, Towson, MD 21204-7582. Phone: (410) 337-1640. E-mail:]