Access Feedback: APCs, EMTALA concerns pose copay challenges

Do you have collection strategy?

Two issues are standing in the way of successful copay collection at her facility and many others, says Kathy Pajor, director of patient access services at St. Vincent’s Medical Center in Bridgeport, CT. She’d like some feedback from access colleagues who may have developed strategies for addressing either of these concerns.

The first has to do with the vagaries of the outpatient prospective payment system, which became effective Aug. 1, 2000. The system involves a predetermined rate of reimbursement called ambulatory payment classification (APC).

"Collection under APCs at the front end of the revenue cycle process is a challenge," Pajor says. "The self-pay portion is difficult to calculate because it is patient-specific. An example would be if you and I were both Medicare-only patients going in for the same procedure with the same physician, except the physician orders additional tests on you due to multiple diagnoses. You would have a different copay than I would."

Even during the procedure, she points out, the physician could decide to order an additional test that will affect the payment calculation. Or, she adds, one patient might have a reaction to the anesthesia, while another may be in recovery a longer time, also altering the amount of the copayment.

At present, Pajor notes, she is addressing the situation by trying to determine the amount of the average copay for various procedures. "I took a 10% sampling of each major diagnostic test or procedure and calculated an average self-pay portion. Patients will be informed that the required deposit is an approximation and that they will either get a refund or have a small balance to pay."

The problem with that approach, of course, is the back-end work and the cost to produce a bill or process a refund check, Pajor says. Does anyone have a better way of collecting APC copays at the point of service?

To facilitate some payment collection, she notes, the hospital’s financial counselors process applications for Medicare patients who also may qualify for Medicaid coverage.

"If the patient is deemed to be over assets,’ we will determine an approximate deposit and collect that or a portion — with a payment plan — up front. The medical center is in an urban setting. Our patients who have Medicare-only insurance may qualify for Medicaid, which would cover the self-pay portion we are trying to collect at the time of service."

ED collection challenging

How do people increase point-of-service collections in the ED, Pajor wants to know, if they’re adhering strictly to the provisions of the Emergency Medical Treatment and Labor Act (EMTALA)?

Although she can see the financial and operational benefits of a process whereby a nurse triages the patient, determines his or her condition is not an emergency, and then sends the person along for registration and copay collection, she points out that there is still a gray area regarding EMTALA regulations and collecting money before being seen by the physician.

"Triage involves ranking, the order in which patients will be seen, according to how they present signs and symptoms," she adds. "In the medical screening requirement, which is beyond triage, it’s a physician [preferred] who determines if a patient is not in an emergency situation." Access staff cannot delay the medical screening examination to obtain authorization or collect money (42 U.S.C. 1395dd).

"How have other hospitals worked around that [restriction]? What types of business plans have been developed to address this?"

Complicating the situation at her facility — and making collection a particular challenge — is a large unregistered alien population, Pajor notes. Hospitals have to carry the burden of that, and try to be aggressive in collecting self-pay dollars."

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