ED collections starting at near-zero? Simply asking can get 300% increase

Put in a ‘policy with teeth’ for emergency department

While the emergency departments (EDs) at St. Luke’s University Health Network in Bethlehem, PA, had a cash collection program in place two years ago, it was inconsistent and informal, according to Annemarie Mariani, patient access director. “Some people in the ED did a good job with asking for co-pays, while others were more uncomfortable with this aspect of the job,” she says. “The result was sporadic collections that varied among the five network hospitals, with no goals or tracking systems in place.”

Partnering with a consultant, a comprehensive educational program was developed and implemented. The program included the “who, what, where, why, and how” of collections. In addition, a thorough assessment of volumes and payer mix at each facility was completed to establish “collectability” standards for each hospital.

“Collection rates started to climb as we focused more and more on keeping the goals in front of the staff,” says Mariani. “We also monitored patient response closely, looking for any changes in the patient satisfaction surveys or negative comments, which we have not encountered.”

An incentive program was established with two goals: The facility has to meet 75% of the total monthly goal for cash collection, and each registrar must collect an average of $500 monthly over a six-month period. “If achieved, the representative gets 2% of their collections, paid semi-annually,” says Mariani. “The first payout was in January 2013, and four of the five facilities achieved the 75% collection goal.”

Forty-four employees received bonus payments totaling $5,162 and ranging from $50 to more than $250, reports Mariani. “We anticipate these bonuses will rise significantly in the second payout, now that staff see what may be achievable,” she adds, and Mariani notes that the total collection goal for the EDs for the fiscal year ending June 30, 2013, is $1.04 million. “At the end of January, cash collection stood at $506,763 — just $70,000 below the goal.”

Just ask consistently

Simply by asking patients for payment consistently, ED collections have increased 300% in the past year at Mercy Hospital Springfield (MO), reports Jeff Brossard, BSHA, CHAM, director of patient access.

“Our average ED point-of-service collections per month was less than $25,000. We now collect in excess of $80,000 a month,” he says. “The biggest hurdle was getting our coworkers comfortable asking for money. Once we finally crossed over that barrier, we saw drastic improvement.”

While staff had collected copays in the ED for several years, this year it was made a top priority, says Brossard. “Healthcare is very unique, in that there are really no other businesses or services that you can say, ‘Bill me later.’ As an industry, health-care has set that precedent,” he explains. “Getting that mindset to change was probably the biggest challenge.” Here are the approaches used by the department:

• Staff members consistently ask for a copay or a deposit toward services for self-pay patients.

“By no means are we bullying anyone or requiring any type of payment, but we do ask for payment consistently at time of service,” Brossard says. Staff members consistently inform patients of their estimated financial obligation or what insurance says they will owe.

“Obviously, in an ER environment, people are not planning for this visit. They may not understand their benefits fully, and the tensions run high,” says Brossard. “The more consistent we are with our process, the less of a shock or surprise it is to patients.”

• If patients are unable to pay, staff members provide them with a receipt and a self-addressed, stamped envelope and ask them to send in payment.

“We do have people who will turn around and send the payment to us the very next day, whether it’s just a copay or a large deductible,” says Brossard.

• Staff members calculate the patient’s out-of-pocket responsibility using a price estimation tool based on a 12-month history of average charges for the patient’s acuity level.

At the time of the ED registration, staff members often don’t know what tests or procedures will be done, which makes calculating an accurate estimate difficult. “Even a patient who has commercial insurance might not have a flat rate copay,” notes Brossard. A patient might be responsible for a $150 copay plus 10% of the total bill, for example.

• Collection amounts are posted publicly every day.

Brossard says he’s noticed a “good healthy competition” in his department. “One thing I’ve noticed is that if we do not keep it in front of our eyes and theirs constantly, collections start to slack,” he adds. “If we stop putting out the daily information, we see a decline over a period of just a few weeks.”

• Top collectors are recognized publicly and sometimes taken to lunch.

“If the department reaches a big goal we’ll have a pizza party or ice cream social,” he says. A recent example: The department set and exceeded a goal of collecting $790,000 in January 2013. To congratulate the team for reaching the collections goal, Brossard’s department had an ice cream party and gave each employee a star-shaped lapel pin stating “Great Job.”

• Staff members are given simple scripting to rely on.

“Any time you are asking for money, you run the risk of somebody being upset about it,” says Brossard. “The more prepared staff are to calmly answer the patient’s questions, the easier and less frightening it is.”

Brossard says scripting can be as easy as saying to the patient, “Mr./Mrs. Smith, we have verified your benefits with your insurance company, and they show that you are going to have an estimated outof-pocket cost of X dollars. How would you like to take care of that today?”

• Monthly collection goals were set for each registrar, based on the hours and shifts worked.

“It’s not a matter of, ‘You didn’t make goal this month so you are getting written up.’ But if after a period of months, someone has not attained their goal, then you really do have to take it to the next level of counseling,” he says. “We have found that it is easier to work with smaller goals.”

For example, if a employee has a $5,000 monthly goal and is scheduled to work 22 days during that month, setting a $250 per day target is much easier to handle. “If the co-worker consistently works toward $250 a day, they will make their $5,000 monthly goal,” says Brossard.

Still, acknowledges Brossard, “there were and still are individuals who are resistant to collecting. Putting in a policy with teeth has made all the difference.”


For more information on increasing emergency department collections, contact:

Jeff Brossard, BSHA, CHAM, Director, Patient Access, Mercy Hospital Springfield (MO). Phone: (417) 820-9089. Fax: (417) 820-4880. Email: Jeffrey.Brossard@Mercy.net.

Sherry Jones, Patient Access Supervisor, Emergency Department, Greater Baltimore (MD) Medical Center. Phone: (443) 849-6794. Fax: (443) 849-8776. Email: sljones@gbmc.org.

Annemarie Mariani, Patient Access Director, St. Luke’s University Health Network, Bethlehem, PA. Phone: (484) 526-4077. Email: Annemarie.mariani@sluhn.org.