Self-pay patients: Quarterly benchmarking report A supplement to the Patient Access Resource Center
Dear reader, The cost of healthcare is rising and fast. Based on its survey of 1,557 employer plans, global consulting company Mercer Health & Benefits says private-sector premiums in 2008 will increase by 6.7%. Many patients are running away from private insurers and employers health plans, simply because they cost too much. Approximately 47 million Americans are uninsured. If they get sick or injured, they have to pay their hospital bill usually 100% of it. Who is responsible for collecting the bill? It is a revenue cycle team effort that involves the patient access manager, the patient financial services director, the coder, and the biller. Self-pay patients are a fact of life; getting them to pay is too. The Patient Access Resource Center presents its first-quarter benchmarking report on self-pay patients. This report will show how facilities handle self-pay patients. It will discuss the payment programs facilities have in place and whether they offer discounts for prompt payment or automatic discounts for self-pays. It will delve into how providers use financial counselors. And what about when the patient leaves without even making a copayment? Do facilities rely on outside vendors to collect the bill? Or do they try to collect the money themselves? We hope this report helps you think about those patients who are uninsured. We hope it helps you think about the ways you collect their payments. After all, the best policies may be outside your access doors. Sincerely, Dom Nicastro Senior Managing Editor HCPro, Inc. 781/639-1872, Ext. 3413 dnicastro@hcpro.com Self-pay patients
Most facilities have only first-shift financial coverage A respondent reported that of all his facility s patients, 86% are self-pay. Other respondents quoted numbers as high as 70% and as low as zero. All facilities seem to be ready for self-pay patients at least for eight hours of the day. Of our respondents, 87% said they have financial counselors on hand from 9 a.m. to 5 p.m. Only 4% of our respondents said they have financial counselors around the clock (Figure 1). Ultimately, facilities strive for 24-hour financial assistance, but most do not have it, according to industry experts. Eighteen percent of respondents said they have counselors on hand either at admitting or at bedside, and 48% said they have counselors on hand at both (Figure 2). Some respondents said they have business offices or counselors available only by phone. One respondent said he or she sees the need to offer financial counseling for as many hours as possible. Another respondent said his or her staff members split shifts to cover more hours. Sarah Garrett, patient access services applications analyst for the Olympic Medical Center in Port Angeles and Sequim, WA, says her facility makes sure it has access to the self-pays after they leave. Her department has 20 staff members and is a 126-bed facility. For the registration side, we make sure that we have photo ID, valid demographics, offer a financial aid application, and suggest that the patient complete it and turn it in to patient accounts, Garrett says. We reassure the patient that we will arrange payment plans and run all self-pay accounts through VeriLink [a registration software program] to see if there is some other insurance coverage. Based on responses from our survey, examples of where hospitals deploy their financial counselors include: Down the hall from admitting and at bedside A business office By phone and at bedside as needed In patient accounts By appointment In the customer service office In the ED, outpatient and inpatient Office manager and patient insurance coordinator n Figure 1 Are there financial counselors available to patients at your facility? Figure 2 If you have financial counselors available at your facility, where are they deployed? 9% 4% 11% 34% 7% 87% 48% 24 hours 9-5 hours None at all At a desk only in admitting At bedside Both Other March 2008
Pay now, pay less: Prompt payment gets discounts Almost 80% of survey respondents say they offer discounts for self-pay patients who pay promptly. The most popular number for a discount is 10%; of our respondents, 28% said they offer this discount for prompt pay (Figure 4). However, as our survey indicates, there is a lot more to discounts than just a straight number. Some examples, from responses in our survey, include: 20% if the account is more than $300 Sliding scale, based on balance 20%, and with director approval can go to 35% 15% if paid within one month, 5% within three months 40% if paid at the time of service Individualized based on amount and terms 25% if paid within 30 days, 20% within 31 60 days, and 15% within 61 90 days 50% if paid at time of service True self-pay has a 40% discount to be paid within 60 days, one provider wrote. So it has a prompt pay component mixed in. Another offers discounts only within 30 days of the initial charge: It s 40% if payment is made prior to discharge or leaving the office. It s 30% if the bill is paid off within 30 days, and none past 30 days. n Figure 4 If there is a prompt-pay discount, how much? 28%7% 53% 17% The survey revealed that it is not automatic for selfpay patients to get a discount, but it is certainly more the norm 65% say they offer some sort of discount. We have a 10% discount total for self-pay patients that has 10% 20% 2% 30% Other 80 70 60 50 Figure 3 Are there any kinds of discounts for prompt pay? 78% Yes No Figure 5 Do discounts help in terms of getting the patient to pay faster? 80 70 60 50 65% Yes No 40 40 35% 30 20 10 0 22% 30 20 10 0 Self-pay patients
Tracking the bill: Outside vendors used often So just how does a facility track a bill that leaves the office? About 60% of respondents said they use an outside vendor (Figure 6). We do a monthly review by a dedicated staff person, one respondent said. The accounts are flagged in the system. Several facilities do their share of internal monitoring perhaps checking bills once per month but then hand a bill over to a collection agency once it gets past a certain amount of time. At 45 days from final bill or final insurance payment, the account goes to one of two precollection companies, reports one respondent. Automated red flags are common today. When the patient is called, he or she receives a letter or a bill, and we then offer the discount if paid within 10 business days, a respondent said. The survey asked whether facilities had an earlyout program for all self-pay and/or low-dollar self-pay accounts. Twenty-two percent of respondents said that they offer such a program. The discounts... are only applicable for true self-pay, not after insurance, one respondent said, and are applicable and offered only if the bill is paid within 30 days; then reverts back to charges. Our early-out program is handled by an outside vendor who tries to collect, and if there s no luck, then the claims go the collection agency who is handled by the same vendor, wrote one respondent. One facility has two companies for precollection. All accounts go to them 45 days after final bill or final insurance payment, except for accounts less than $10: Those we write off, one respondent wrote. There are the self-pay patients who may not realize they are eligible for other programs. Respondents were asked whether they have trained professionals to identify those patients and link them with the right coverage, and almost all responded that they do. Yes. At the time of an admission, social work or the nurse case manager starts the interview process, one writes. If the patient meets any criteria the staff who is interviewing begins the enrollment or contacts the agency. One facility has a formal training program as well as a published document on the process of identifying patients who could use financial help and the resources available. We have an economic service worker on-site from the Department of Human Services, as well as an additional on-site service that focuses on self-pay patients as well as others without secondary insurance, one respondent said. The financial counselors are educated regarding Medicaid, crime victims, catastrophic illness, etc., to make the referrals. It s a big problem, one respondent said, to get patients to complete applications and bring in necessary information and data to review for criteria compliance. It s amazing, the respondent wrote. Patients can get free service but will not bring in employment or pay info or sign forms requesting assistance. n 60 50 40 30 20 10 0 Figure 6 Do you use an outside vendor to monitor bills that are past due? 59% 41% Yes No March 2008 5
Get cash at least some: Most collect copayments The best tracking system in the world can allow healthcare providers to chase self-pay patients all over the country, but providers need to collect some cash before the patient leaves. In our survey, 55% of respondents said they collect some cash in the ER before patients are discharged; more than half say they collect 0% 25% of the final bill outside the ER. Sometimes, clinicians have to get involved. Patients are identified with a form they are to bring to the ER checkout, one respondent wrote. Electronic system also has an alert notifying both registration staff and nursing of patient need for financial counseling. If the indicator is still there at time of discharge, the discharge nurse escorts the patient to financial counseling office next to ER. And facilities with an automated communications system constantly talk about the status of a patient before he or she leaves. The RN taking care of the patient notifies admission when the patient is stable and can be spoken with about the money owed, a respondent wrote. This notification happens through our ED bed board product. Patients are Figure 7 What percentage of copays/charges are paid at the time of service? 16% 11% 7% 1% 51% 7% not discharged until the financial indicator is removed by admissions. Other methods reported in the survey include: Discharge materials are handled by billing office staff members Figure 9 Does the ER collect copays and other monies due at the time of service? 60 50 40 58% Figure 8 Who collects the cash? 36% 28% Central cashier 74% Admitting/registration staff collect copays before service 39%7% 42% ER Other Yes No 15% 17% 30 20 0-25% 41-60% 76-99% 10 26-40% 61-75% 100% 0 6 Self-pay patients
Financial counselors monitor daily activity Referral given as the patient leaves the facility Patients are asked to pay at time of service Color-coded face sheets notify discharging staff members before patient dismissal Bright pink tags on charts and tickler are noted in the computer when patients check in Electronic tracking system monitors the patient before he or she leaves Nurse takes discharge papers/scripts to a registration staff member who verifies demographics and collects copayments or refers to patient accounts for the correct payment plan A deposit from all bad-debt patients is required prior to service for nonurgent services If the patient is self-pay, questions are asked to determine whether he or she should be given indigent program and refer patient to financial services n Staff Competency in Patient Access: Tools, Tests, and Tips for Building a Successful Team You rely heavily on your staff members to run a smooth patient access department. Empower them to succeed from the start. Hire the right people, train them well, and help them grow. To get the most out of your staff members, you have three major challenges: 1. Establishing a hiring process that harvests motivated and talented employees 2. Creating an organized orientation that will prepare your staff members to handle the complexities of their job and provide them with the necessary tools to perform their duties 3. Implementing a detailed program to evaluate and reassess staff members, and using the data to develop initiatives for performance improvement Staff Competency in Patient Access: Tools, Tests, and Tips for Building a Successful Team, by Michael S. Friedberg, FACHE, CHAM, is the ultimate resource for you to meet and exceed your organization s competency requirements. It presents the tools you need to hire the right people, enable them to do their job, and keep your organization running efficiently. Customizable tools on accompanying CD-ROM Take advantage of the more than 50 tools available for you to download and adapt to fit your specific needs: Sample quality assurance programs Competency exams and answer keys Job descriptions Competency clues and reminders for staff members Individual scorecards to track progress And more For more information, visit www.hcmarketplace.com or call HCPro customer service at 800/650-6787. March 2008 7
03/08 SR0408 This special report is published by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Copyright 2008 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. If you have questions, contact customer service at 800/650-6787, fax 800/639-8511, or e-mail customerservice@hcpro.com. Opinions expressed are not necessarily those of the editors. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. HCPro is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. 8 Self-pay patients