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Space redesign, counseling boost ED collection efforts

Before, charts were walking out the door

When Tara Tinsley, CHAM, began working as an access supervisor in the emergency department (ED) at Children’s Health Center in Birmingham, AL, registrars weren’t asking for copays, and were collecting only about 10% of the dollars that could have been collected up front. "When I first got here, we may have been collecting $5,000 in a month, and we probably see 5,000 patients in that time, so that’s not a lot."

In addition, says Tinsley, who also is department trainer, "we had a considerable amount of patients who would actually leave with their charts" without being discharged. She shared her experience with Hospital Access Management in response to a request for information on ED cash collection practices in the May 2003 issue by Lori Judge, MS, HAS, director of patient financial services at St. Claire Regional Medical Center in Morehead, KY.

The 26-bed treatment area wasn’t far from a handy exit, Tinsley continues, and with three nurses releasing patients at the same time, it was easy for patients to elude the checkout process. "The nurses are so busy," she adds, "and they don’t have ownership with the clerical piece [of the process]."

One of the things she — along with the ED supervisor for the second and third shifts — pushed for from the start, Tinsley says, "was a means to increase our visibility to the nurses as well as the patients, to minimize the number of charts that walked out."

"We needed to have discharge more controlled and closer to the nursing staff, so we moved that area to the back, inside the ED," she notes. "We had instant improvement with visibility, as well as a decrease in the number of charts leaving."

The increase in collections wasn’t quite as immediate, Tinsley says. "It took a while to train our community that we would ask for copays. It just took repeated efforts, just getting [registrars] in the habit of saying, Your copay is X amount. How would you like to take care of it?’"

Registrars then inform patients of the methods of payment that are available, she adds. "If the patient says [he or she] can’t pay, or didn’t have to pay last time, they just repeat [the information] and say, Next time, keep that in mind.’" Sometimes patients can’t pay the full copay, Tinsley says, and the hospital will accept a partial payment. Four years later, she notes, ED cash collections are up to between $25,000 and $30,000 a month.

MSE requirement is strict

Many hospitals define a medical screening exam (MSE) — for purposes of the Emergency Medical Treatment and Labor Act (EMTALA) — as what happens at the point of triage, Tinsley notes. That means that after triage, registrars at those facilities are able to talk with patients about payment, she adds. The process at Children’s Health is more restrictive, she points out. "Our MSE is when the physician has gone in and started seeing the patient. So our patients are triaged, and then registered with general information."

However, Tinsley notes, a software program that runs within the registration pathway allows registrars to verify benefits in real time. We get the insurance card and make copies, but we don’t discuss payment." Once that initial registration is completed, she says, "we let the nurses know and they proceed with secondary assessment or other treatment." If a patient is flagged as self-pay during the initial registration, Tinsley says, one of the hospital’s two financial counselors goes into the treatment room after the physician has been in. "They wait and watch the tracking board to see when [the physician] has gone into the room."

Counselors make the difference

The counselors — who work from 8 a.m. to midnight — talk to patients about the programs for which they may qualify, determine their ability to pay, and provide applications for those programs if appropriate, she notes. That piece of the process has been in place about 3½ years, Tinsley adds.

The big advantage of having counselors in the ED, she points out, is that more patients can be certified for financial help immediately, and without wasting time applying for the wrong program. In some cases, Tinsley notes, the counselors find that the person does have coverage, but just didn’t bring an insurance card.

For patients who receive treatment on weekends, Tinsley adds, financial counselors follow up by telephone and the process typically is completed within three days. "Without the financial counselors, [uninsured patients] would be sent a self-pay bill, and then the full bill cycle of a month or more would run," she says, before the patient would be identified as a candidate for financial aid.

Financial counselors have guidelines showing whether patients would qualify for Medicaid, or for the less restrictive All Kids, an Alabama initiative for children whose parents’ income level places them just short of qualifying for Medicaid, Tinsley explains. "During counseling, they tell the patients which program they’re applying for, she says. "A lot of times we have people thinking they should try Medicaid, but [if they don’t meet guidelines], that just delays their getting help."

Young patients can be certified immediately for the Jefferson County Program for Uninsured Children, she notes. If they later qualify for Medicaid assistance, that coverage is retroactive, allowing the county program to be reimbursed.

As for Judge’s speculation that investing in financial counselors in the ED would pay off, Tinsley says her experience confirms that. "[Financial counselors] definitely help," she says. "They identify things that are not usually found out until after the bill has dropped. Our bills drop within five days, so they’re doing all this within five days. Without them, we would have more accounts receivable days."

[Editor’s note: If you have feedback on this issue, or comments or information to share regarding any access topic, please contact editor Lila Moore at (520) 299-8730.]