New discharge station aids ED copay collection

Full registration occurs after treatment

Cheryl Staske, MS, director, hospital registration centers, at Carle Foundation Hospital in Urbana, IL, has some feedback for access colleague Kathy Pajor, who seeks advice in the March issue of Hospital Access Management on how to increase point-of-service collections in the emergency department (ED) while strictly adhering to the provisions of the Emergency Medical Treatment and Labor Act (EMTALA).

Pajor, director of patient access services at St. Vincent’s Medical Center in Bridgeport, CT, asks what plans are in place to allow successful copay collection, despite the fact that EMTALA prohibits access staff from delaying the medical screening examination to obtain authorization or collect money.

At Carle Foundation Hospital, Staske says, her department uses a two-step procedure to increase collections. (To see process flowchart, click here.) "Our process in the ED," she explains, "is that patients are seen in triage first. When they are finished, they come to [access staff] and complete a half-sheet form, five or six key pieces of information — name, address, date of birth, medical record number at Carle Foundation Hospital."

After that, Staske continues, patients go back to the treatment room, where they receive the medical screening exam, and whatever treatment is necessary. "When they are finished being treated, they are directed or escorted to the registration discharge station."

At that point, she says, access employees do a complete registration, verifying insurance, getting consent forms signed and completing a Medicare Secondary Payer form if necessary.

"Through an on-line eligibility system called Nebo, we see if we can verify the [amount of] the copay," Staske says. "Some of the biggest struggles are that ED patients often don’t carry an insurance card, or they have insurance that is not part of the on-line eligibility system."

The Nebo system covers some eight third-party payers, she says, including Aetna, Cigna, Humana, Blue Cross Blue Shield, and the Illinois Department of Public Aid, among others. They represent about 80% of the insurers with which the hospital does business, Staske adds.

However, she notes, "many [third-party payers] do not list the copay. Some just list the percentage of charges, but because we don’t know what the charges will be at that point, so we can’t calculate [the copay]."

The hospital is considering charging a flat rate in such cases, Staske says, but the concern is that this will create additional work for billers on the back end. "We might need to have a conversation with them."

Because the full registration is done after treatment is completed, she says, the challenge is making sure patients make that last stop at the discharge station. "There is a percentage of patients who bypass us."

Since the discharge station was instituted in December 2002, Staske notes, that percentage has dropped from 35% to about 22%, thanks primarily to the cooperation of clinical staff. "The nurses and physicians help us by directing patients [to the discharge station]."

ED physicians not always cooperative

Mary Nellums, CHAM, admissions manager at the University Hospital of Arkansas in Little Rock, would like some suggestions on how to gain the cooperation of ED physicians in handling nonurgent Medicaid patients.

"When Medicaid patients come to the ED but are not really urgent cases, we are trying to get the physicians to send them to their primary care physician (PCP)," Nellums says. "Sometimes these patients use the ED as a clinic."

Medicaid requires a referral from a PCP to cover the ED visit, she notes. "We’ll try to call while the patient is here [at the ED], but the PCP won’t give a referral." That leads to Medicaid refusing to cover the visit, Nellums adds.

"The ED physicians are not educated as far as the importance of getting that referral and the impact on the back end," she says. "[The hospital is] denied payment because there was no referral and the patient just had a headache."

Although the medical director of the ED understands and supports the effort to get proper referrals, at first, he was getting conflicting reports on the situation, Nellums adds. "We were telling him what was happening, and the physicians were saying that they were cooperating."

Access staff began keeping records, she says. "We’re now providing reports of Medicaid patients who showed up and for whom we didn’t get a referral. We show when we gave the physician notice to call and he wouldn’t."

Nellums welcomes ideas from access colleagues who have been effective in getting physicians to work with access staff to obtain Medicaid referrals.

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