Do registrars inform patients about options?

Access processes under scrutiny

Nobody ever told me financial assistance was available." This is a typical comment from patients who are struggling to pay hospital bills, reports Jessica Curtis, JD, director of Boston-based Community Catalyst's Hospital Accountability Project, a national consumer advocacy organization focusing on healthcare issues.

In some cases, patients really weren't given the information, and other times, patients just don't remember being told. Either way, patients' account balances have typically already gone to collection by the time they seek help, Curtis says.

"Patients are delaying care because they are afraid of acquiring medical debt," says Curtis. "Patients with chronic illness are putting off preventative care and instead, coming to the emergency department when there is some type of emergency."

No consistent approach

Patient access leaders can expect much more scrutiny about what and when patients know about financial assistance, says Curtis.

"The problem has gotten a great deal of media attention in the past year," she notes.1,2,3 A 2012 study found poor compliance in New York hospitals.4

"This isn't just a one-off incident where patients are falling through the cracks in one hospital," says Curtis. "There isn't a consistent approach for how patients should be notified."

Twenty-two states require hospital to notify patients about financial assistance in some way, notes Curtis, and the Patient Protection and Affordable Care Act requires hospitals to widely publicize their financial assistance policies. (For information on free healthcare laws and regulations in each of the 50 states, go to

In addition, the IRS has proposed more detailed, prescriptive proposed rules on notifying patients, including requiring hospitals to work with community partners to get out the information, and the American Hospital Association has its own guidelines for informing patients. (To access the AHA Policies & Guidelines on Billing, Collections, Tax-Exempt Status, and Community Health, go to

"Right now, federal rules affect only nonprofit hospitals. But this is a practice all hospitals should be looking at," advises Curtis. "The burden is shifting from the patient to the hospital staff to tell patients upfront about financial assistance, so patients can take steps early to apply. It's kind of like informed consent, but on the financial side."

Patients uninformed

Many non-profit hospitals are not adequately informing patients about charity care policies, despite federal requirements. In Community Catalyst's survey of 99 hospitals, 15 did not mention the availability of charity care, and less than half provided written materials.5 John A. Gale, MS, research associate at the Muskie School of Public Service at the University of Southern Maine in Portland, says, "Hospitals still have a long way to go in terms of making this information available. There is a lot of room for improvement."

Gale did a study in 2007 of critical access hospitals. He found that the vast majority had a formal charity care policy in place, but they made the information available only if patients specifically requested it. Less than half made the materials available in multiple languages.6

"If patients aren't adequately informed about charity care, it can not only cause public relations problems for the hospital, it can also jeopardize the hospital's nonprofit tax status," says Gale.

Gale points to Provena Health in Mokena, IL, where portions of the property tax exemptions were stripped away because of its debt collection practices and level of charity care provided. "They had a lot of complaints about very aggressive collection practices," he says. "It has worked its way through the courts and was eventually upheld."

Illinois state officials are looking at the way hospitals provide charity care and trying to set minimum levels of charity care performance, notes Gale. IRS officials are looking at charity care practices, how decisions are made, under what circumstances hospitals can deviate from their policies, and how well the information is made available to the public. "Hospitals are being looked at by a variety of policyholders and stakeholders," Gale says. "Patient access staff need to understand that this is a very, very big issue."

Access is key

Curtis recommends that registrars simply tell patients, "We have programs available to help if you think you might have difficulty paying." (For more information on this topic, see "Do you tell patients about charity care?" in Hospital Access Management, September 2012, p. 104.)

Patient access employees are "the first and best line of defense to avoiding problems, by informing patients upfront," says Curtis. "It also makes good business sense for hospitals. It is always better to get reimbursed than not to."

Patient access staff are the best ones to let patients know about charity care options, adds Gale. "They are the front line. The time to let people know about this and begin to collect this information is when the patient is right in front of you, instead of waiting until there is a 90-day receivable for that account," he says.

Underinsured patients might not realize they will end up with a large out-of-pocket responsibility down the road, he adds, so it's important for them to get the information early in the process.

More patients will presumably have coverage as a result of healthcare reform being implemented in 2014, says Gale, but the same processes still will be needed. "Every single uninsured person won't be covered, and illegal immigrants will still be seeking services," he notes. "Also, there is a greater cost shift to patients, so deductibles and copays may still be subject to charity care or discounted care."


1. Silver-Greenberg J. Debt Collector is faulted for tough tactics in hospitals. New York Times, April 24, 2012. Accessed at

2. Alexander A and Raynor D. Hospital suits force new pain on patients. Charlotte Observer, April 23, 2012. Accessed at

3. Bernstein N. Hospitals flout charity aid law. New York Times, Feb. 12, 2012. Accessed at

4. Benjamin ER, Slagle A, Tracy C. Incentivizing patient financial assistance: How to fix New York's indigent care program. Community Service Society, New York, NY. February 2012.

5. Pryor C, Rukavina M, Hoffman A, et al. Best Kept Secrets: Are Non-Profit Hospitals Informing Patients About Charity Care Programs? May 2010. Community Catalyst/The Access Project.

6. Loux S, Coburn A, Gale J, et al. The Community Benefit and Impact of Critical Access Hospitals: The Results of the 2007 CAH Survey. March 2008. The Flex Monitoring Team, University of Southern Maine.


For more information on informing patients of financial assistance, contact:

• Jessica L. Curtis, JD, Director, Hospital Accountability Project, Community Catalyst, Boston. Phone: (617) 275-2859. Email:

• John A. Gale, MS, Research Associate, Muskie School of Public Service, University of Southern Maine, Portland. Phone: (207) 228-8246. Fax: (207) 228-8138. Email:

• Kathy MacGillivray, MHA, Access Management Services Director, Robert Wood Johnson University Hospital, New Brunswick, NJ. Phone: (732) 937-8909. Email:

• Mia Poliquin Pross, Esq., Associate Director, Consumers for Affordable Health Care, Augusta, ME. Phone: (207) 622-7083. Fax: (888) 214-5233. E-mail: