In Search of 2 Percent: Comprehensive Strategies for Increasing POS Collections

Cecelia Russell, CHAA

Highlands Regional Medical Center (HRMC) is a 192-licensed-bed, community-owned, not-for-profit hospital with a 16-bed emergency room accredited for chest pain, heart attack and stroke treatment. The medical center offers a variety of outpatient diagnostic testing and surgical services. It is a part of the larger Highlands Health System, which includes the medical center, family practice and specialty clinics, the Highlands Center for Autism, and a behavioral health facility. Our Patient Access department is comprised of 30 staff members who provide scheduling, pre-registration, outpatient, emergency and inpatient registration, switchboard and financial counseling services. Most of our staff are skilled in multiple areas of the department.

Due to staffing shortages and a declining population in the service area, both inpatient and outpatient volume at HRMC has shrunk during the past fiscal year. Eastern Kentucky is an area plagued with poverty and economic decline. A Kentucky audit of rural hospitals showed the uninsured rate for our service area has been cut by more than half since the introduction of the Affordable Care Act, but much of that is credited to Medicaid expansion. Despite these challenges, fresh leadership has managed to motivate and empower Patient Access staff to reach for and meet point-of-service collections goals.

The first performance indicator in NAHAM’s AccessKeys is POS Collections to Revenue. Benchmark levels range from “Good” at 1 percent to “Best” at 2 percent of net patient service revenue. At HRMC, we have had recent success reaching the first benchmark in this key performance indicator (KPI). Through technology, education and accountability, our staff surpassed the 1 percent mark in December 2016 and are on track to reach 1.5 percent in 2017.

Technology

In January 2016, HRMC implemented an electronic system to estimate patient financial responsibility. This works in conjunction with our insurance verification system. Prior to implementation, Patient Access staff requested deposits dependent on service type (e.g., outpatient radiology, laboratory, emergency, surgery, etc.) from patients who had not met their insurance deductibles. While this strategy helped to increase collections over previous methods, you can see that as the year progressed, collections dwindled as patients began to meet their deductibles and staff requested payment from fewer patients.

The new system maps service type by CPT code or template to the patient’s respective insurance contract. Deductibles, co-insurance and co-payments are calculated against the adjudicated charge to provide the best estimate to the patient.

As you can see in Figure 1, we struggled to collect even 1 percent of net patient revenue at the point-of-service prior to implementation of an electronic solution. During several months in 2016, Patient Access staff were able to increase POS collections up to 400 percent over the previous year.

If you are considering the purchase of a custom solution to estimate patient financial responsibility, there are some important things to keep in mind:

• Estimates are only as good as the information available. Make sure that the firm you partner with has the most up-to-date chargemaster, as well as your most recent insurance contracts. Also note that if not available through an electronic interface, you may have to call the insurance company to verify benefit information.
• Assign someone within Patient Access to take ownership of the product — ideally a supervisor or manager. Encourage staff to reach out to this contact with questions or potential system issues. After duplicating the issue, reach out to the service provider immediately to resolve the problem. Inconsistencies between requests for payment and the explanation of benefits (EOB) a patient receives will diminish the credibility of estimates you provide and create additional work for the billing office later.
• Communication is key. Weekly project calls with the service provider will give your team the opportunity to discuss any potential issues and prevent those issues from falling through the cracks. Don’t be afraid to ask any questions relevant to the product. Often, your representative will have encountered the issue before. On the flip side, you may help them learn how to make the solution better for all of their clients.

Education

Three years ago, when I joined the Patient Access team here at HRMC, I was not trained to ask patients for financial responsibility. Point-of-service collections were dismal and almost non-existent. Through leadership of an interim director, we began to ask for co-payments or deposits from patients with a single insurance who had not met their deductible.

In preparation for implementation of an electronic system, Access staff were required to go through a training course to learn how to use the estimate tool. This gave them an opportunity to ask questions of representatives from our partner and test its features. Leadership were also able to indicate when use of the tool would be most appropriate. Support was available as staff began to utilize the tool in the live environment.

In addition to use of the estimate tool, Patient Access staff were provided scripting to use when asking patients for payment. We also interviewed some of the staff who were having an especially difficult time with collections. Those staff often used the verbiage, “Can you pay today?” or “Do you want to pay today?” Given the choice, many patients would rather wait for the bill. Representatives are instructed to present the estimate, explain how the estimate is calculated and then inform the patient, “We accept cash, check or credit card. How would you like to pay today?” Staff who employ some form of this verbiage are much more successful in their efforts.

Action and Accountability

How will you know if the tools and education provided are being utilized or are moving your team toward meeting their goals? Routine audits and data analysis are crucial to determining if your efforts are helpful and can differentiate between staff who are collecting well and those who are struggling.

Historically, collections have been low for emergency and admissions encounters at our facility. Representatives working in this area are now provided with a monthly collections report. The document identifies all of their opportunities for collections, as well as how many they were able to convert and how many opportunities they missed. Through improved documentation, we can see that overall, registrars are doing much better at identifying opportunities for collections and having the appropriate conversation with patients. Collectively, emergency and admissions registrars have boosted collections on total estimated opportunity by four points from July to December 2016.

For scheduled testing, pre-registration staff work in conjunction with representatives in outpatient registration to inform patients of estimated responsibility in advance, gain commitment and collect. Formerly, collections were only obtained on the date of service. However, we have begun to offer patients the option to pay during the pre-registration process to save time on the day of their appointment. As more patients are taking advantage of this option, we are noticing a reduction in missed opportunities and an increase in collections.

Early in 2016, we started an incentive program for those who exceed their peers. While this seemed to work for a while, we began to see full participation when monthly collections minimums were implemented. Risk is balanced with reward, and as seen in November and December, collections skyrocketed. Patient Access staff now understand that calculating and requesting patient financial responsibility is a necessary part of their job that is vital to the revenue cycle and the organization.

Conclusion

Striving to achieve any goal takes hard work and continuous dedication. If your firm is searching for 2 percent, implementing an estimate solution, whether homegrown or purchased from a vendor, is a likely way to help boost collections. Educate Patient Access staff to be knowledgeable about insurance benefits. Help them identify opportunities for collections and encourage them to be consistent with their requests for payment. Hold them accountable for an important part of their job. Informing patients of the estimated cost of their service is the responsible thing to do and will help lead to higher point-of-service collections.

Previously, our staff were told that they were performing as well as could be expected due to the level of poverty in our service area. In 2016, it is estimated that only 25 percent of encounters registered at the facility presented opportunity for collections. While it is true that a large number of our patient population are insured by Medicaid or are dually insured, it is important for leadership and staff to realize that the goal set for monthly collections is a ratio and is related to our specific facility’s revenue. Dependent on strategy, 2 percent collections to revenue is an obtainable benchmark for any facility.

Cecelia Russell is a Patient Access supervisor at Highlands Regional Medical Center in Prestonsburg, Kentucky. She is a NAHAM Communications and Publications Committee member and has helped re-energize the Kentucky Association of Healthcare Access Management (KYAHAM).