Are patients angry at access? Make sure they're happy before they leave

Head off all complaints

A young woman is fuming because she just learned about a $5,000 deductible before her insurance coverage kicks in. An elderly man is loudly complaining because he doesn't understand why he can't have anything to eat or drink until he's been seen by a physician. Parents are raising their voices because they don't want to wait to see a doctor before getting their child's test results.

Regardless of the reason, an upset, disgruntled patient is dangerous for your department. To make matters more pressing, customer service has become the new catch phrase for patient access departments. This is for good reason, since it clearly impacts the hospital's bottom line.

If the number of patient complaints involving access increases, your department will have "decreased employee morale, employee turnover, a stressful work environment, and a poor reputation within the hospital," warns Susan M. Milheim, senior director of patient financial services at the Cleveland Clinic in Independence, OH.

Access staff at the Cleveland Clinic use the "HEART" acronym to remind them of the things involved in excellent customer service. This stands for:

• Hear the patient.

• Empathize with the patient.

• Apologize for the situation.

• Resolve the situation.

• Thank the patient.

Staff have index cards with these words taped to their computers to remind them of the steps they should follow during difficult situations.

"Too often, we get upset and respond negatively to an unhappy patient or family member," says Milheim. "We need to listen. The patient needs to be heard and to feel as if we understand their problem and how they feel. But, that is only half the battle."

The other half is doing something about the patient's complaint, and right away. "We need to resolve the situation for the patient. Resolving means more than directing the patient to another area," says Milheim. "It means taking the initiative and getting the patient what they need and not passing the patient along."

No more surprises

A small amount of well-timed communication can ward off some explosive complaints. "Patients should be informed upfront about things," says Amy M. Kirkland, CHAA, patient access team leader for the emergency department at Palmetto Health Richland in Columbia, SC.

For example, when a patient signs in, that's the time to inform him or her that they are not to eat or drink anything until they have been seen by a doctor. The same is true for test results; patients should be informed prior to their test or procedure that they will get the result when they see the doctor.

"And explain the importance of why the doctor will discuss the results," says Kirkland. Say to the patient, "It is important that your doctor goes over your test results with you in case you have any questions. They will be available to answer any questions you have concerning your tests and/or results."

With insurance coverage becoming increasingly complex, it's sometimes difficult for you — someone who deals with it every day — to comprehend. Thus, it should come as no surprise that patients are coming to you with little to no understanding of their benefits.

"We have seen an increase in confusion for our patients," says Milheim. "So the more information we can provide to the patient, the better."

What the patient will owe should be communicated at the time of scheduling to the best of your ability, to avoid "sticker shock" after the fact. "And if a patient becomes annoyed with a registrar about their copays, we direct the patient to talk with a financial counselor," says Milheim. "This allows for a more comfortable conversation, with an expert who can talk with the patient and fully explain their benefits in a confidential area, instead of at a registration desk."

At MultiCare Health System in Tacoma, WA, scripting is used to create a consistent, customer-service-oriented experience for each patient. "We actively seek ways to minimize surprises to the customer," says Angie Pike, the organization's director of customer service. "For example, we will contact patients at pre-admission to make financial arrangements. We have found that patients typically respond positively to these calls."

Pike says that the biggest source of potential patient dissatisfaction with patient access at her organization involves point-of-service collection. As part of this process, staff collect copays, outstanding deductibles, and estimated co-insurance at the bedside or at a centralized registration location. "It can be a challenge to approach a patient who is in a patient bed. Our staff are sensitive to that issue," says Pike.

As unlikely as it may seem, there are some good customer service opportunities in this scenario. For one thing, access staff can help patients begin the necessary financial aid paperwork early in the process.

"While point-of-service collection can be a challenge, we have also found that it has given us the ability to reduce patient anxiety, especially if they will be unable to pay for services due to financial limitations," says Pike. "Often, these are patients who are sent to collections unnecessarily. They don't understand the resources available to them from the system and don't communicate with us after they leave our facility."

Ideally, all patients would know their estimated out-of-pocket expenses and be aware of the hospital's collection procedures. "However, because this is a relatively new trend in the industry, it can be surprising to have someone come to the bedside requesting payment," says Pike. "This is why our pre-service center exists."

Staff at the center contact pre-scheduled patients before their surgery or procedure to confirm demographics and insurance benefits. At the same time, they request payment of their copay, outstanding deductible and/or estimated co-insurance. If the pre-service center staff are not successful contacting the patient, this process moves either to a centralized registration area or to the bedside on the day of the surgery or procedure.

"There are many times when people simply don't understand their insurance policies well enough to know what's expected of them," says Pike. "By contacting them up front, we can clearly set expectations at the onset."

For instance, prenatal patients are typically younger, relatively healthy people who have not had a great deal of experience maneuvering through insurance coverage for inpatient stays. "They have no idea what to expect. By notifying them up front, the surprise, and in some cases, anxiety can be reduced," says Pike. "It may not be ideal for every mother-to-be, but overall, we have found that our new moms respond better to the request for payment prior to their arrival."

Re-direct anger

Patient may have a legitimate reason to complain, but in fact, their gripe may have nothing whatsoever to do with your department. Regardless, the situation might generate a complaint letter with misguided anger directed at access. "Patients often confuse patient access staff with other staff," says Kirkland. "It is important that patients understand the role of each individual involved in their care."

For example, they may confuse patient access with a unit secretary or other employee at the front desk of a given area. To prevent this type of confusion, Palmetto Health Richland uses a standard colored dress code for each role in the emergency department. "Also, each patient access employee strives to stress to each patient their role in the beginning of their process as well as the end of the process," says Kirkland.

Pike says that at times, patients do express concerns that are outside of the scope of access staff. For example, there may have been a delay prior to treatment and the patient feels he or she has been ignored.

That doesn't mean that access staff don't get involved in these concerns, however. Staff are instructed to use the "LEARN" acronym: They listen, empathize with the patient's experience, apologize sincerely, respond by either contacting the unit staff or asking if there is anything they can get for the patient, then nurture the relationship with a sincere "thank you" for bringing the concern to their attention. "Unit staff will then follow up to verify that the patient's needs have been met," says Pike.

At times, a patient has lost his or her insurance due to a termination in employment but failed to follow through with COBRA benefits. This is now discovered at the time of registration, when the patient enters via the emergency department or as a direct admit. 

"Since the patient now has no insurance, we will investigate the possibility of them gaining coverage through COBRA," says Pike. If the patient has not investigated this at all or previously decided against COBRA coverage, a financial counselor will contact the previous employer to determine if the patient is eligible for COBRA. 

If so, the financial counselor contacts the COBRA administrator to determine how much is owed from a premium perspective and how much retroactive coverage will be allowed. The patient or his or her representative is contacted, informed of this, and premium payment is sought.

"If the patient is unable to pay their retro COBRA premiums, MultiCare will more than likely pay for all outstanding premiums in the short term in order for coverage to commence," says Pike. "Patients are very appreciative of this process. It usually allows them to gain coverage for a length of stay that is very expensive and would result in a large out-of-pocket expense by them otherwise."          

At MultiCare, any staff member can provide the patient or family with a small gesture of apology. Staff also can sign out up to $50 worth of items at the hospital gift shop without seeking permission.

"This has proved to be helpful in certain circumstances," says Pike. "We trust our staff to use the gifts appropriately, and they have not failed us. We do, however, remind them that the gift cards should only be given after they have sincerely apologized and empathized with the patient's experience. The gesture will be empty without these."

Gift cards can be given for any number of reasons. "In the inpatient setting, we often give gift cards to family members for the cafeteria so that they can take a step back," says Pike. "It's very stressful for families to be with loved ones who are sick. Sometimes, simply giving them a moment for everyone to clear their heads has tremendous benefit for all involved."

When a gift card is given, staff simply write a brief explanation on a log for why the gift card was used. "In order to receive a replenishment of gift cards, the log is simply faxed to customer service, which tracks issues so that trends can be identified and acted upon," says Pike.

[For more information, contact:

  • Amy M. Kirkland, CHAA, Patient Access Team Leader, Emergency Department, Palmetto Health Richland, Columbia, SC. Phone: (803) 434-6652. E-mail:
  • Susan M. Milheim, Senior Director, Patient Financial Services, Cleveland Clinic, 6801 Brecksville Rd., Independence, OH 44131. Phone: (216) 636-7210. Fax: (216) 636-8088. E-mail:
  • Angie Pike, Director of Customer Service, MultiCare Health System, 315 Martin Luther King Jr. Way, Tacoma, WA 98415. Phone: (253) 403-6122. Fax: (253) 459-6235. E-mail:]