Access Feedback

What if care’s given, consent not obtained?

Some refuse to sign, fearing obligation

The dialogue among Hospital Access Management readers continues as access managers work to fine-tune processes and enhance cash collection in the emergency department (ED). Natalie Woodburn, RN, patient registration supervisor in the ED at St. Mary’s Hospital in Leonardtown, MD, has a question regarding the obtaining of "consent for treatment" in cases in which treatment has already been provided. At her facility, she explains, an employee known as a guest relations associate greets patients as they enter the lobby of the ED and performs a "quick registration" — getting name, date of birth and Social Security number — in order to match the person with an existing hospital account if possible.

From there, Woodburn adds, patients go to a triage nurse, who directs them to "fast-track" care or to the main ED operation, depending on their condition. After the person is in a treatment room, Woodburn says, the registrar may go in before or after care has been provided, depending on how quickly the physician or other caregiver comes in. "We don’t stop the physician or nurse from going in, but if they don’t go in right away, registrars do go in and begin to register," she says. Registrars typically complete the registration, get the consent, and place a wristband containing name and date of birth on patients before they have received any service other than screening.

There have been times, however, that complete care was rendered before the registration was completed, Woodburn notes, and before insurance information was provided or consent for treatment obtained. In some cases, she says, people who have brought in minors for treatment have refused to sign the consent form after care has been provided because they are afraid of being responsible for the bill. "Where do you stand if you’ve provided treatment without consent and the person refuses the obligation to pay?" she asks. "I understand there is something called implied consent, but that doesn’t stand up in a court of law."

Nurse cooperation sought

Woodburn also welcomes suggestions on how to get nurses to buy in to the effort to get payment — or at least billing information — from ED patients before they leave. "We don’t have a discharge station, but it is part of our policy and procedure for clinical staff to send patients back to the registrar if the registration hasn’t been completed," she says. "[Nurses] are not good about complying with that. They’re more concerned with getting the patient in and getting them discharged. They want to have a one-hour turnaround."

Because in most cases hospital nurses have not had to be aware of "what happens if we don’t get paid," Woodburn notes, helping to facilitate the payment process "is not on the top of their list."

"It is on the top of our list," she adds, "because we get feedback from the business office." Although she and others are working on getting hospital administration to put pressure on clinical staff in this regard, Woodburn says, the comparatively low tab for ED visits makes getting paid for them a low priority.

Laura Fawcett, a Detroit-based manager for the consulting firm Cap Gemini Ernst & Young, says overall organizational buy-in is the key to a successful collections process. "If the top is supportive, everybody else seems to fall in line," she notes. Fawcett suggests that Woodburn do some mathematical calculations to demonstrate to administrators the amount of revenue the hospital is missing by failing to focus on both upfront collections and stringent discharge procedures the ensure proper registration.

Although administration’s view might be that collecting after the fact is acceptable, she notes that her firm estimates it costs about $25 per account to send out a bill. With copay amounts often in the same range, Fawcett adds, "if you don’t collect up front, that’s really all of your [profit] margin."

Among her clients, Fawcett says, "we are seeing [hospitals] give incentives" to boost collection efforts. "Based on historical collection rates, they set monthly targets that are both staff-specific and for the overall department." Employees who meet or exceed these goals receive awards, such as gift certificates, she adds. "The only other thing that helps — and it’s not an easy fix — is [addressing] how the department is laid out," Fawcett points out. "When the patient flow is set up so that there is a checkout area, it really ensures that [registrars] get the patients before they walk out the door."

Without the buy-in of top management, of course, that change isn’t going to happen, she notes.

[Editor’s note: If you have feedback on this issue or other concerns of interest to access professionals, please contact Lila Moore at (520) 299-8730 or by e-mail at]