No detail too small as system prepared for POS collection

Multidisciplinary team led effort that began with CFO directive

When Palmetto Health in Columbia, SC, decided to launch a major point-of-service (POS) collection effort almost three years ago, commitment came from the top down, and preparation was extensive, says Charlene Cathcart, director of admissions and registration.

"We established a multidisciplinary team that included not only patient financial services and registration, but also the ancillary departments and the physician practices — everybody who touched patients or had an impact in some way, either on the front end or the back end," she says. "We also included our public relations department, because we knew we eventually needed to get the word out throughout the [health system’s] three hospitals," Cathcart explains. "We needed everyone’s buy-in and participation in the process. They needed to understand the impact on Palmetto Health of not doing POS collection and the benefits on the back end when you do," she continues.

It was important that staff throughout the three-hospital system, which has more than 1,200 total beds, knew the thinking behind the effort, Cathcart points out. They could then respond appropriately if patients said something like, "I can’t believe those admitting people asked me for money!"

The cash collection project started at the request of the health system’s chief financial officer, who heads a summit that oversees the organization’s revenue cycle, notes Rebecca Richardson, CPA, CIA, director of management support services. "As [the summit] worked through those issues, he saw that we were missing opportunities with POS collection, that we were not doing a good job of asking [for payment], that most employees didn’t think to ask, and that there was a reluctance to ask because of fear of rejection," she adds.

Richardson, who works in corporate finance and reports directly to the CFO, originally facilitated the multidisciplinary team and also oversaw the creation of a standardized POS manual that includes "from beginning to end" the expectations associated with the collections effort.

One of the reasons for the manual, Richardson explains, is that while Cathcart has a protocol for teaching her employees, not everyone who registers patients reports to admissions and registration. "In other areas, there is quite a variety of knowledge levels," she says. "We needed a guide to set forth standards for the folks in radiology and in other ancillary areas. There also tends to be turnover in the [registration] role. The further we went [in writing the manual], the more we thought of something else to include," Richardson notes.

"We determined in the beginning that we couldn’t ask people for money without making sure they understood the whole shooting match," Cathcart adds.

Among other things, she notes, the manual includes a letter from the CFO, policies and procedures for handling cash and getting receipts, frequently asked questions, and an explanation of all the forms that are used.

"Some people are very visual, so we flow-charted the entire process," Cathcart says. (See Cash Receipts Handling.)

Determining payments

Palmetto Health uses the electronic verification system, Real-Time Eligibility, (formerly called Medifax) that brings up the benefits data for some insurances. If registrars can find the exact amount a patient owes, that’s what they try to collect, Cathcart explains. In the areas in which immediate insurance verification isn’t done, however, the health system asks patients for pre-defined deposits, she says.

To come up with the appropriate amount for those deposits, Palmetto ran three years’ worth of payment data, by service, Cathcart adds. "So we looked at three years of payments by patients who had heart catheterizations, for example, and determined on average what they owed," she says.

If the figure is high or low, it is adjusted later, but because the health system was very conservative in setting the amounts, Richardson notes, "we found that we were not writing a lot of refunds."

If a Medicare patient comes in for a screening mammogram, the amount to be collected is $11.72, while the amount for a gastrointestinal procedure is $100, Cathcart says. "We tried to make it pretty simple for registration staff. If the patient has South Carolina Medicaid, which doesn’t require a copay for all services, we identified the services for which it does require one," she says.

Patients without insurance are asked to pay the same amount as those who are insured, adds Richardson. "Care is often perceived as free, and part of the strategy is to help educate the community. [Asking for payment] is a way to start the conversation."

No detail was too small when it came to facilitating the process, Cathcart notes.

In addition to teaching registrars how to operate credit card machines, she says, management had the machines standardized throughout the health system. This enabled them to reduce fees and to make it easier for registrars to work in different areas. It also made sure the machines could take all major credit and debit cards, which they couldn’t do before.

While staff were being shown the fine points of counting cash in front of patients, writing receipts, and expressing thanks for the payment, it was decided that receipts and other paperwork should be the same color at all three hospitals, she continues. "For example, if we were going to give the patient the white copy of the receipt, keep the pink copy, and send the yellow copy to accounting," Cathcart says, "we kept that concept with the daily control log and even with the deposit slips. We wanted people to think, This is yellow — it goes here.’"

Comprehensive education effort

The education provided to help registrars feel competent and comfortable in all areas of POS collection was detailed and comprehensive, she notes, and included everything from standard scripting for conversations with patients to role-playing to presentations by outside experts in the field.

Physicians were sent letters informing them about the collection initiative, Cathcart says, and the entire hospital was targeted with a six-week campaign called "Remember Bill." Signs posted throughout the facility described a famous person named Bill, and people were encouraged to guess who the person was, she explains. "A key point that we wanted people to understand [about the collections program] was at the bottom of the signs each week," Cathcart says. "For example, we put that there was a cost savings on the back end if we didn’t have to send bills. To get people to read that, we had them try to figure out if the person described on the sign was Wild Bill Hickok or Bill Cosby," she adds.

Every other week for six weeks, people would submit the answers to try to win a prize, and three winners were drawn from the entries with the correct answer. Meanwhile, "we got across six key points." Cathcart explains.

The key to the success of the initiative, which resulted in a 30% increase in collections the first year and a 40% increase the next, is communication, Richardson notes. Her advice to those embarking on such a program is to make sure there is buy-in from senior management and to set patient expectations as early in the process as possible. Palmetto Health, for example, put letters explaining the collections effort in the surgical packages patients receive from physicians.

As part of her initial oversight of the project, Richardson explains, she arranged for signs in English and Spanish to be placed at each registration location. "We also [have staff] discuss it in the scheduling process, and we accept payment by credit card during the preregistration phone call," she says. "It’s the perfect place to bring it up. Some were dubious when we put [a credit card machine] in that area, but we have had some success with that." Richardson adds.

[Editor’s note: Charlene Cathcart can be reached at (803) 296-5187 or by e-mail at]