Should you switch to point-of-service billing?

Will it help with collections problems?

Point-of-service billing is one way for your ED to improve its collections, says D.W. "Chip" Pettigrew III, MD, FACEP, medical director of the ED at Athens Regional Medical Center (GA). "This is a growing trend, and the trend will continue to grow as reimbursements continue to decline ," he predicts. Arranging for service payments while the patient is still at the ED may make billing more efficient, as well.

Point-of-service billing provides the following opportunities, says Pettigrew:

    • to assure that all of the billing information obtained by registration is correct;
    • to discuss with the patient that, although payment up front is not expected, payment is expected for every ED encounter;
    • to get the patient to commit to payment verbally; and
    • to obtain copayments and deductibles without having to send out mailed bills to the patients.

The ED at Athens Regional is in the process of implementing point-of-service billing, reports Pettigrew. "It takes a strong push from senior hospital leadership after convincing them that point-of-service billing makes fiscal sense," he says. "After that, it takes a complete cultural change in the ED to have the patient care nurse direct the patients to the point-of-service billing desk at discharge, rather than load the patients up in their cars and send them on their way."

Most EDs would benefit from point-of-service billing, says Pettigrew. "The variety of patients coming to EDs is not exclusive in any one area and, with each type of ED (large or small, public or private, suburban or inner city), there will be a significant number of patients who will be able to pay at the point of service. This is more efficient than sending them a bill through the mail, followed with more expensive mailings and phone calls," he explains.

Point-of-service billing is not an attempt to chase away the indigent population, or make them uncomfortable, Pettigrew argues. "It is a proper attempt by a legitimate business entity to get paid for services rendered," he says. "Point-of-service billing is a timely opportunity to remind patients of their responsibility to pay their ED bills. This is done in a manner that does not interfere with federal obligations mandating upfront medical screening examinations and emergency stabilization."

The primary advantage of point-of-service billing is getting paid more quickly, notes Robert Williams, MD, FACEP, research investigator at University of Michigan School of Public Health and former president of ACEP. "A 90 to 120 day turnaround time is the norm. So if the patient gets seen on January 1, you may not get paid until April or May. Also, Medicare might sit on it for a month or two before they pay you," he says. "If you have a good billing company, they should get the bill out in 30 days, but you still have to wait the 90 to 120 days."

Point-of-service billing would save 30 days of that time period. "Billing patients is an accounts receivable problem, because you are always owed money. If you could bill those patients immediately, it would help your cash flow," says Williams.

Also, systematically, new technology could make point-of-service billing a feasible option, says Williams. "In the future, we’ll be able to capture data at the time of the patient’s visit in some kind of paperless form," he explains. "If you used a handheld computer and could immediately transfer the data to a billing company, instead of having somebody in-house do it, that would be a viable alternative."

A currently vaible option for all EDs?

However, it’s currently very difficult to generate a bill at the time of service in the ED, notes Williams. "It’s a lot harder than it sounds to do it right," he says.

One problem is that patients often don’t have their insurance information with them. "I don’t think that people are as reliable and consistent in bringing insurance information with them to the ED, as they are when they’re admitted to the hospital," says Williams. "Frequently they don’t have their billing information, which is a serious encumbrance to billing onsite."

Without adequate information, an accurate bill can’t be generated, Williams explains. "In our billing operation, half of the calls we receive about patients’ bills are are related to the fact that when they came in, they didn’t have insurance information. So the bill might mistakenly say the patient didn’t have insurance," he reports.

Also, in order for in-house point-of-service billing to be effective, you would need a full time coding person to evaluate the record, Williams argues. "Our group has our own billing company, and we spend a lot of time and effort developing coding experts, many of whom are nurses," he says.

Only large EDs with very high volumes can justify having a full time coder on staff, says Williams. "Our coders can code 30 patients an hour because they’re pros at it, but very few EDs have volumes of 30 patients per hour," he notes. "If it costs me $30 an hour to pay a coding person, and they code 30 patients an hour, it costs me a dollar per patient. But from an efficiency standpoint, if you see 2 or 3 patients an hour, it’s just not cost efficient."