Stricter EMTALA readings prompt policy changes for patient co-payments

Providers work to ensure EDs are in order

Chances are the policy your hospital developed more than 10 years ago for the the Emergency Medical Treatment and Active Labor Act (EMTALA) needs to be revised.

With the federal Office of the Inspector General (OIG) and the Health Care Financing Administration (HCFA) issuing red alerts on all compliance matters, providers are making strenuous efforts to ensure their emergency department (ED) procedures are in order.

After reviewing the EMTALA regulations in the wake of a special OIG/HCFA compliance bulletin issued in December 1998, the Portland, OR-based Providence Health System took a closer look at its own ED operations, says Patricia Weygandt, on-site access services manager at Providence Milwaukee Hospital. That examination led to a new interpretation of the rules and a change in the Providence policy regarding insurance co-payments, she says.

Prior to June 1999, Providence collected ED co-pays upfront as part of the registration process that followed triage of patients by a registered nurse, she says. "In June, when we were made aware of this bulletin, along with the ED staff, we decided we needed to change our practice. Our feeling was that [EMTALA] was stating that no co-pay collections could occur until after the medical screening exam, which would determine if the [case] was emergent, and after the patient had been stabilized."

When registrars stopped asking for co-pays upfront, however, the collection rate plummeted, she says. At Providence Portland, for example, the percentage of co-pays collected before the patient left the ED went from 33% in May to 3% in June, when the practice was changed, she says. Attempts to collect went from 94% to 3%.

"We would say to the patient, Would you please stop back at the desk after you’re seen by the physician? There are a few more things to take care of.’ But many times the patients would just leave or, if [a registrar] was not readily available, become impatient and then leave."

To discover the best way of collecting co-pays on the back end of the process, the health system put together a regional continuous quality improvement (CQI) team made up of ED clinical and access services staff, with Weygandt as team leader, she says. "We also had two team facilitators, who really pulled everything together as far as data collecting was concerned. They guided the team through the complex process of examining every possible solution. Their expertise in process improvement was invaluable.

"It took a long time to hammer out the process," Weygandt says. "The team met every week from the last week of July to Sept. 8, and there was lots of brainstorming."

Educating staff about the new process — and soliciting their feedback on its effectiveness — was an integral part of the project, she notes. (See related story, p. 4.)

The first thing the team had to determine was how access staff would reach patients and collect the co-pays after the patients had gone to the back of the ED to receive treatment. The solution for Providence Milwaukee, the smaller of the three Portland-area hospitals, was different from that for Providence St. Vincent Medical Center and Providence Portland Medical Center, she adds.

At the two larger facilities, the process involved using a clinical software program, made by Logicare Corp. in Eau Claire, WI, that produces discharge sheets, Weygandt says. It works like this (see chart, p. 5):

1. The patient checks in at the triage desk, and the registrar enters into Logicare just enough information to get the patient into a treatment room. (Emergent patients are sent directly back for treatment.)

2. The nurse triages the patient.

3. Access personnel register the patient in HBOC. The registration data automatically transfer into Logicare through a link between the two programs.

4. The registrar puts a note in Logicare, saying the patient requires a co-pay.

5. After completing the examination of the patient, the physician sees the note in Logicare and selects the option "discharge after co-pay" on the computer screen.

6. The line containing that patient’s name begins blinking on computer screens throughout the ED, and the registrar assigned to monitor the screens goes to that patient to ask for the co-pay and complete the process.

If the physician forgets to select "discharge after co-pay" and an RN is already with the patient giving discharge instructions, that nurse will page the co-pay registrar, who will then go to the patient, Weygandt explains.

When the Logicare solution was implemented at Providence Portland, the co-pay collection rate went from 3% to 30%, and the percentage of attempts at collecting the co-pay went from 3% to 50%, she says.

At Providence Milwaukee, which does not have the level of Logicare necessary for the above process, the team decided to use "the sticker method," which Weygandt says would work for any hospital without a computer solution (see chart, p. 6):

1. The patient is registered in the HBOC system, and the registrar identifies the need for a co-pay.

2. The registrar puts a red sticker on the nurse’s ED notes.

3. Once the exam is completed, the physician activates a green discharge light, and the RN verbally notifies the registrar, who attempts to collect the co-pay. (The close proximity of the access services desk allows verbal notification, but contact could be made by phone or pager, she says.)

Leeta Stoughton, clinical systems manager for regional emergency services for the system’s Portland service area, built a feature into Logicare that shows there is a need for a co-pay, Weygandt says. That lets the physician know to select the option "discharge with co-pay."

To allow the system to better track the collection rate, registrars can enter into HBOC one of four codes indicating the following:

• The co-payment was attempted and collected.

• The co-payment was attempted and not collected.

• The co-payment could not be collected because the patient was not responsive.

• The registrar was unable to determine the co-pay and so did not collect it.

Providence officials hoped to implement the new co-pay procedure without increasing the number of full-time equivalents (FTEs), but that issue is still being addressed, Weygandt notes. At one facility, indications are that more FTEs will not be required, while at the other two there may be a need to add employees. Those potential staff additions, however, also would be related to an increase in patient volume, she adds.

Solution suits hospital’s size

A small facility and convenient layout give the 44-bed Mt. Graham Community Hospital in Safford, AZ, a jump on complying with EMTALA regulations, says Julie Johnson, admissions manager.

Four years ago, the hospital discontinued having registrars interview emergency department (ED) patients before the physician’s exam because of EMTALA concerns, Johnson notes. The process now works like this:

1. An ED medical technician checks the patient in, recording just the name and date of birth, and gets the patient’s vital signs and chief complaints.

2. The ED tech sends the patient to an examination room and gives registrars a slip of paper with the basic patient information and a number indicating which exam room the patient is in.

3. Registrars enter the information into the computer, generate an account number for the patient, and give it to the ED tech.

4. The physician completes the exam, and the ED tech tells the registrar, "Ready for No. 3," or whatever the appropriate exam room is.

5. The registrar completes the registration.

Despite its small size, Mt. Graham sees as many as 1,000 patients a month in its ED, and volumes are increasing, Johnson says. The hospital, which plans to increase inpatient beds from 44 to 59 and ED beds from 10 to 18, is in the process of an $18 million expansion, she says. The new layout will be even more conducive to easy communication between ED clinicians and registrars, she adds.

"Right now, [registrars] are adjacent to the ED, separated by a wall with a window, and the ED techs or nurses can usually get our attention through that window," she says. "It does take a conscientious effort on the part of the ED techs to put us into their procedure and notify us that the patient is ready to be registered."

Although the ED techs can do a quick registration in the computer, registrars want to maintain control of that process because of quality assurance and compliance concerns, she says. To make sure registration personnel keep that control, "we promise them an account number within a minute, preferably 30 seconds," Johnson adds.

The ED has been doing "fast registration" since August 1999, and has plans to modify the registration process further, she notes. "We’re looking at having the patient already treated and discharged by the physician before [doing any sort of registration]." On the way out, the patient would stop by the discharge desk and the registrar would do the entire registration, she adds.

The idea is feasible, Johnson says, because the exit from the ED will be a "keypad only" door that will prevent patients from leaving without registrars’ knowledge.

When the expansion is complete, ED clinicians and registrars will have even easier access to each other’s offices, she says. There will be an opening in the adjoining wall and a drawer — "like the old bank teller system" — that opens directly onto a registrar’s desk, Johnson adds. "That will save a couple of steps, which could be helpful depending on how busy we are."

When the slip of paper is put in the drawer, she says, the ED tech or nurse will activate a light that alerts the registrar.