Stop losing out on revenue: ID costly gaps in POS collections

Processes need revamping

Even if your registrars have expertise and comfort with collecting, there are probably missed opportunities for point-of-service (POS) collections that add up to a lot of missed revenue.

“A significant amount of revenue is being missed due to our overall collections program being decentralized, fragmented, and with no way to provide an integrated estimate of a patient’s out-of-pocket cost,” reports Mela Gant, director of patient access services at Oregon Health & Science University in Portland. “We are falling well shy of industry [best practices] for upfront collections.”

Two years ago, New York City-based PricewaterhouseCoopers did a comprehensive assessment of the organization’s revenue cycle operations, Gant says. PricewaterhouseCoopers reported that best practice for acute care hospital POS collections and upfront patient payments is 1% to 2% of net patient revenue, and it identified POS collections as a key area of opportunity for the organization, she says.

Because professional services and anesthesia services had POS collection processes independent of the hospital’s, some patients heard from all three areas about making payments prior to or at the time of service. “This lack of coordination created confusion for patients,” says Gant. “It caused breakdowns in our understanding of what amount, exactly, the patient needed to pay when being admitted for services.”

The department recently purchased a patient liability estimator, which incorporates hospital, professional, and anesthesia charges into one estimate. “The estimator uses our insurance contracts and fee schedules to determine allowable charges,” explains Gant. “It is in the final stages of being built and ready to move to the next phase of validation.”

The tool incorporates patients insurance benefits via an interface that populates demographics and the individual patient’s benefits, including copay amount, the remaining deductible amount, coinsurance, and whether the out-of-pocket maximum was met. “Having all three entities working independently put us at risk for overcollecting,” adds Gant. For example, if a patient has met $1,200 of an annual maximum out-of-pocket cost of $1,500, and all three entities collect the remaining $300, the patient would be owed a $600 refund.

At the same time, a multidisciplinary team of stakeholders from patient access, ambulatory services, and professional and hospital billing came together to reengineer the hospital’s POS collections workflow. Patients now work with one entity to make pre-service payments, payment arrangements, and apply for financial assistance if needed. The new process will be piloted in several large surgical practices, oncology services, labor delivery, the emergency department, and high-dollar radiology services, says Gant. “We will no longer work independently of one another,” says Gant. “In our new workflow, the patient will be provided with the estimate for all services at once.” (See related stories on how the hospital obtained feedback on POS collections from patients, and how it increased POS collections by $1.5 million.)

Here are some other challenges patient access departments are facing with POS collections:

• Collecting for outpatient procedures performed in clinics.

“These sometimes slip through, such as IUD [intrauterine device] placement and LEEP [loop electrosurgical excision procedure] procedures,” acknowledges Katie Harwood, CHAM, admissions manager over financial advocates and ED registration at University of Utah Health Care in Salt Lake City. She estimates that $38,000 went uncollected for IUD placement in the past 12 months.

“We have expanded our collection efforts to include these types of procedures,” says Harwood. “After confirming support from the gynecology service line leadership, we changed criteria on our work queues to include the service type Gynecology and the CPT codes related to the procedures.”

• Collecting patient responsibility after insurance.

At University of Utah Health Care, members of the patient access staff have expanded their collection efforts to patient responsibility after insurance, says Harwood. This patient responsibility amount is based on the insurance benefits quote, the facility’s contract with the payer, and the history of the procedures performed over the past 12 months.

“Patient benefits are verified. The information is entered into our patient liability estimator -- an internal tool that was created for our use,” says Harwood. “Our team cash collection for preservice has increased by 28%, compared to the same timeframe last year.”

• Collecting outstanding balances.

Stacy Calvaruso, CHAM, assistant vice president of patient management at Ochsner Health System in New Orleans, says, “This is our biggest missed opportunity for collections.” Registrars don’t collect outstanding balances at scheduling and/or registration, Calvaruso adds.

“We have residual balances carrying over close to 40% of the potential that was to be collected on their outstanding balances,” she says. “Some patients bring their statements in with them and pay.”

The department is converting to a new system. Because there are outstanding balances in the legacy system and the new system, the time that it takes to pull this together during scheduling and/or at registration obstructs patient flow, she explains. “We have made a choice to postpone this until the first quarter of next year, so we have the opportunity to work through some of the legacy system items,” says Calvaruso.

Holly Hiryak, MNSc, RN, CHAM, director of hospital admissions and access services at the University Hospital of Arkansas in Little Rock, says there is a recent emphasis on “pushing collections and financial counseling closer to the front, including outstanding balances.” The department is implementing an automated financial screening tool to facilitate collections, beginning in the emergency department and radiology.

“Radiology registrars are screening for authorizations,” says Hiryak. “If these are not in place, the case is placed on hold and the scheduling department is contacted to complete the process.”

• Collecting when patients have “variable obligation” policies.

Clinics are seeing many more of these policies, which make it more difficult to estimate the patient’s out-of-pocket expenses, says Calvaruso.

If a patient schedules an office visit appointment for a medication refill and routine follow-up, for example, staff members typically would collect a co-payment at the time of check-in. “Depending on how the visit is coded, this could be considered a ‘well’ patient visit, which does not require a co-payment. In this instance, we must refund the co-payment,” says Calvaruso.

However, if the patient has a “limited” and/or “variable obligation” plan, the hospital might not be paid at all for that visit. The plan might only cover five office visits per year up to $100 and pay only $25 per diagnostic test up to $250 per year.

“The information from an auto verification service states that the patient is covered, with no indication of limitations,” says Calvaruso. “The only way that you can validate this is by talking to a representative.”


For more information on increasing point-of-service collections, contact:

Stacy Calvaruso, CHAM, Assistant Vice President, Patient Management, Ochsner Health System, New Orleans. Phone: (504) 842-6092. Fax: (504) 842-9108. E-mail:

Mela Gant, Director, Patient Access Services, Oregon Health & Science University, Portland. Phone: (503) 494-6588. Fax: (503) 494-6366. Email:

Richard L. Gundling, FHFMA, CMA, Vice President, Healthcare Financial Practices, Healthcare Financial Management Association, Washington, DC. Phone: (202) 296-2920 Ext. 605. Fax: (202) 238-3456. Email:

Katie Harwood, CHAM, Admissions Manager, Financial Advocates/ED Registration, University of Utah Health Care, Salt Lake City. Phone: (801) 585-5567. Email:

Holly Hiryak, MNSc, RN, CHAM, Director, Hospital Admissions/Access Services, University Hospital of Arkansas, Little Rock. Phone: (501) 686-8170. Fax: (501) 603-1243. E-mail: