Special report: Upfront collections
As a staff’s comfort level soars, so does the rate of its collections
Role-playing customer interactions made the difference
Editor’s note: In this issue, Hospital Access Management takes a look at how three facilities are getting a handle on upfront collections. With hospitals continuing to face dwindling profit margins, getting payment at the beginning of the revenue cycle — not months down the road — can make a crucial difference to the bottom line. Access managers are well-positioned to become heroes to their organizations as they take the lead in this effort.
When Evelyn Gullet, MBA, became director of patient access at University Medical Center in Lubbock, TX, a little more than a year ago, no collections were being made at the point of service. The overriding obstacle to any such effort, Gullet found, was registrars’ fear of what they anticipated would be an unpleasant experience.
Registrars didn’t like the idea at all, she says. "They didn’t know how to overcome resistance or aggressive behavior [on the part of patients]." Part of the reluctance, Gullet notes, was because the not-for-profit hospital is a county facility, where the whole concept of collecting money seemed alien. When the hospital administration asked her to spearhead an effort to collect copays and deductibles at the point of service, Gullet asked her staff how comfortable they were with the idea. The response, she says, was that they didn’t feel comfortable at all.
After an extensive inservice on the ins and outs of collections and the opportunity to get some experience under their belt, the staff’s confidence has soared along with the collection rate, Gullet says. Since the effort began in October 2000, in the outpatient surgery department, the amount of copays collected up front has gone from zero to about $25,000 per month, she adds. "Most of the time, people pay the entire amount, or at least 50%. I’d say 85% pay the whole copay." Patients who say they can’t afford to pay are referred to financial counselors, who check to see if they qualify for government assistance, Gullet says.
The two-hour inservice, which included several role-playing episodes, made the biggest difference in the registrars’ attitude toward their new responsibility, Gullet says. The participation of hospital employees from other departments in the role-playing exercises was particularly effective, she notes. It helped registrars to try out questions such as, "Would you like to pay by cash or credit card?" and "How much can you give us today?" with people they didn’t know well, Gullet adds.
An effective collections program, however, is not just about the registration employee, she points out. "It’s also about the community. People have to get used to it." For the most part, Gullet says, that has happened, even though there has been no educational effort, such as running ads in the newspaper announcing the new policy.
Perhaps the biggest contributor to the successful collections effort, she notes, was choosing the right employees in the first place. Since assuming her position, Gullet says, she has replaced at least 10 of 17 employees in the emergency department (ED) business office, including the manager, and five of eight outpatient surgery employees, also including the manager.
Gullet’s focus in hiring, she explains, is on whether the person has a customer service background and the core skill of being a communicator and a listener. "I can teach them the other things [involved in being a registrar]. "I want to know if they can deal with the [hospital] environment, because it can be very, very stressful," adds Gullet. "They’re working not in a hotel, but in a hospital. Family members can be emotional."
When screening potential employees, she says, Gullet asks "What would you do if . . .?" questions to determine if the person is right for the job. "I’ve worked with people who had Harvard degrees who couldn’t do anything for me," Gullet notes. Although she lets her manager handle the initial stages of hiring, she says, Gullet always meets the person, reviews the resume, and asks a few questions herself.
In May 2001, Gullet says, she extended the collections effort into three ancillary registration areas — radiology, physical medicine, and the cancer center. Although the employees who register in those areas do not report to her, Gullet supports their efforts with training and role playing, assisted by a training analyst who works for her. "We talk about what works and what doesn’t work," she says, "and customer service is a big thing. We are making [the collections effort] a friendly competition. Once they’ve experienced success, once they’ve made their first collection, it’s amazing what it does to the motivation."
It’s important, Gullet emphasizes, that she and the trainer provide continuing support with plenty of positive reinforcement. "I send [complimentary] e-mails and cookie bouquets. My experience in other industries is that lots of things people do go unrewarded or unnoticed. They’re trying so hard and doing a wonderful job."
The next level is encouraging the staff to be creative and team-driven, she adds. "It’s not one person being the highest collector. There should be a team goal and a team reward."
ED poses unique challenges
Key to any collection program in the ED, Gullet points out, is a physical layout that promotes an efficient flow of traffic. At her facility, for example, there are two main hallways leading in and out of the ED, which has 28 rooms and sees some 56,000 patients a year, she says. "We’ve tried to create some kind of flow to get patients to see our discharge people and have that financial conversation at the end of the visit," Gullet notes, but she says it’s easy for patients to go out a back door without being noticed by the busy staff. The addition of double doors at the formerly open entrance to the ED, however, has provided some structure, Gullet adds.
Eventually, she says, "we want to have patients automatically pass the discharge counselor. To be successful, you want to keep them in one area, and you want to be in charge of delegating their flow. We’re working toward that, and I have made several written recommendations. I’m trying to benchmark with colleagues and back it up with numbers."
With the less-than-perfect ED layout that is the reality for most facilities, though, it’s important to educate the clinical staff on the importance of leading the patient through the process, from triage to some sort of financial resolution, she suggests. "If people walk out the door [without paying] and they’ve had exams, been given durable medical equipment, that adds up.
"We’re working on it, but we’re in our infancy," Gullet says. "It’s a real challenge. Sometimes I think, Doesn’t anyone understand where their check comes from?’ I meet with the [ED] nurse manager, attend her staff meetings, and try to explain to people what a difference this makes to the bottom line."
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