Increased spotlight on self-pay gives financial counseling an overhaul

Successful move from business office to access department

Higher patient copays and increasing numbers of people who are working but not insured have made the management of self-pay accounts a more crucial issue than ever for most of the nation’s hospitals.

With that in mind, OhioHealth has taken a hard look at providing better service for patients and streamlining financial counseling practices across the board at its Columbus-based hospitals, says Marne Bonomo, PhD, corporate director for patient access. Most notably, the company made the decision to move financial counseling from the business office to the point of service — the access department.

With a change occurring in the management of the business office and a business consultant on-site, the timing was good, notes Bonomo, who assumed her position with OhioHealth in September 2003.

As she sought ways to enhance management of the revenue cycle, an immediate concern was that the financial counseling process was not consistent across the organization, she explains. "It was different on all three hospital campuses and at a key ambulatory clinic whose staff report to access. One financial counselor would start with a patient and might or might not finish the episode. [He or she] might hand off to a financial counselor in the central pre-registration/verification group or to one at the registration site."

Because the reporting procedures were not the same, Bonomo adds, it was difficult to know when the work on an account was truly finished. Under the new plan, she says, "The [person] who starts the process will finish it, carrying through until the patient is either approved for a government program or charity, or until payment arrangements are made."

Another issue, Bonomo notes, was staffing at the system’s largest Columbus-area hospital had dwindled to three or four financial counselors who had not had a manager for more than a year. "We wanted to make sure they had the training and the tools they needed."

A third-party vendor, meanwhile, had been assisting OhioHealth in account management, she adds, but the services provided were not the same throughout the system. In some cases, for example, the vendor might find out if the patient had insurance, and then bump the account back to the hospital, while in others the hospital staff would hand off accounts they felt they couldn’t handle to the vendor, but were not triaging them in the same way.

The different hospitals had different contracts that handled different parts of the process, Bonomo says. Without a uniform contract with one set of prices, she adds, it is difficult to determine if any financial counseling initiative was beneficial.

In January 2004, Bonomo continues, OhioHealth contacted the vendor to "sit down and think about what we might do," and 90 days later — in early April — implementation began at the beta site at the health system’s inner-city hospital, Grant Medical Center.

"Our strongest staff are there; they’re already providing clean, consistent reports," she says. "As we get our process working there, we will roll out to the other two hospitals and the clinic."

One of the benefits of the financial counseling initiative, notes Michael Armintrout, Grant Medical Center’s director of patient access, is that it has created a front-end unity between registrars and financial counselors. "Both areas now have the same focus — to get a payer source for the patient," he adds.

There was much preparation, albeit in a short time frame, Bonomo says. "We looked across all of the campuses and flowcharted our self-pay management process. [Then we] came up with best practice and decided that would be what we would do. We would make sure we were compliant with government regulations and with [the system’s philosophy of] customer service, as well as being efficient."

OhioHealth is very focused on customer service, Bonomo says. The company measures its patient satisfaction results against those of the other clients of the South Bend, IN-based firm, Press Ganey Associates, and makes patient satisfaction a priority in all decisions.

The speed with which the financial counseling initiative was implemented and the accountability that was built into the process reflects the way OhioHealth operates, she notes. What is new and different, Bonomo points out, is that for the first time accountability for results has been moved from the business office to access services. "In the past, self-pay management hadn’t been a big accountability for patient access."

Some positions were in the process of being filled, she says, but among the three hospitals, there are approximately 25 financial counselors. "I don’t know how many people the vendor will need, but [the company] made a commitment to take up the slack."

For the first time, Bonomo says, the vendor will provide "full service," meaning its staff will take the accounts they are assigned all the way through to resolution.

"My staff will triage all of the self-pay accounts and hand off what we can’t handle to the vendor," she notes. "The vendor will handle [the accounts of] discharged patients, out-of-county patients, those with disabilities, illegal aliens, nights/weekend/ED patients that we currently miss, and all accounts still needing work after 45 days." (See ED handoff process.)

In the past, Bonomo explains, hospital staff might have held onto an account too long or missed an account altogether because patients from areas such as outpatient services or the emergency department (ED) were there for such a short time. "We weren’t catching the ED volume and the outpatient high-dollar procedures."

To address such problems, she says, in addition to augmenting with vendor services, financial counselors have been moved into the ED.

In other instances, Bonomo adds, work on an account might have been finished, but staff didn’t realize it and handed it off to the vendor when there was nothing further that could be done.

"If [we do] everything we [can] and it’s just held up at the county for approval," she says, "it’s no good to hand it over to the vendor. But if someone needs to knock on the patient’s door, get more information, then it makes sense to give it to the vendor."

Customer service essential

One of Bonomo’s primary goals, she emphasizes, is to ensure that there is every opportunity to get the bill paid before the account — or the patient — leaves the hospital. "I want my staff handling what is in-house," she adds. "I don’t want to disrupt customer service by being perceived as being unfriendly or pushy . . . or by letting them out the door and saying, Oh, well, it’s a self-pay.’"

OhioHealth will monitor the vendor’s service level closely, Bonomo notes, comparing it against the service provided by the hospital’s own staff by using a patient survey. "We won’t be able to survey every patient, as we do [in-house], but we will pick a big enough random sample that we get a true feeling."

The full-service arrangement represents a new way of doing things for the vendor, she says, and if the program is successful, it will be something the company can use with other clients.

The idea is to capitalize on the expertise of the health system’s own financial counselors, Bonomo says. "We want to augment that — not disrupt what we already [have]. Over time, if we’re able to do more with our own staff, we will do that, but this is an opportunity for the vendor now to have more business than it has had."

Something else that Bonomo’s staff — specifically Armintrout’s team at Grant Medical Center — has developed is a quality tool for financial counseling, with codes that go into the computer system for each part of the process, she explains. "We get a report so that we know if they’re doing everything they’re supposed to do on an account. No one had done that before with financial counseling."

[Editor’s note: Marne Bonomo may be reached at (614) 566-4128 or by e-mail at]