The troubling patient collections approach I encountered at HFMA ANI

Is there something wrong with me?

I asked that question to myself last Wednesday afternoon at the Healthcare Financial Management Association (HFMA) Annual National Institute in Orlando, Florida. Attendees at "Enhancing the Revenue Cycle Experience for Patients" murmured uncomfortably after I asked Patti Consolver and Scott Phillips, senior directors of patient access at Texas Health Resources (THR), why it was not mandatory to ask patients if they wished to apply for financial assistance.

THR, a 24-hospital system with facilities in and around Dallas and Fort Worth, apparently records its phone calls when discussing payments with patients--ostensibly to improve customer service but ultimately to improve upfront collections.

The waning hours of the HFMA ANI had been reached. After nearly two full days of sessions, it had become apparent to me that the goal of the seminars I had attended touting ways to improve the "patient experience" were more about promoting techniques to extract as much money as possible before services were rendered.

The culmination of this was the recording Consolver and Phillips played during their session. The insured patient was scheduled for a procedure the following day, but she almost canceled because of her out-of-pocket costs. The customer service rep was matter-of-fact that she would owe THR almost $5,700 for the procedure, not counting surprises or bills from other providers. Could she pay half when she checked in tomorrow?

Apparently I was one of the few people in the room to detect deep ambivalence in the patient's voice. She explained that she had already shelled out more than $1,500 for prior imaging services, and owes another $1,600 for an ambulance ride.

Adjusting for those payments, the THR customer service rep said she would owe $3,938 instead. Again, could she pay half upfront? The patient said hesitantly she would have to check with her husband to see how they were going to handle it.

Little wonder she was on the fence.

When I asked Consolver why the patient wasn't offered financial counseling, she replied it was up to her to ask for it. "She seemed to accept (the cost)," Consolver said. She added that she paid up the next day.

THR apparently won't offer financial assistance without prompting, "because if the patient is going to pay $1,969 the next day, we're going to go that route first," Consolver said.

Consolver did critique the operator for her approach. Instead of saying, "would you like to pay for that now (and mentioning methods of payments), she apparently should have said "how are you going to pay for that?" I'm guessing if the patient offers cash, THR avoids the 3 percent or more in merchant services fee for processing a debit or credit card.

Admittedly, no one's perfect. Consolver gave the audience the date of the patient's procedure. The recording contained the name of the hospital, the patient's first name, her husband's first name, her date of birth, his date of his birth and their insurer. Under certain circumstances that would constitute a HIPAA violation. However, I'm sure with more practice THR's management will no longer commit that booboo.

THR also records these calls without patient consent because Consolver said Texas law allows that. Of course, if a patient is calling from another state it violates federal wiretapping laws, but that wasn't discussed during the session. Incidentally, THR has more than a dozen years' worth of such recordings sitting on a server somewhere, which I'm certain is a source of comfort for its patients.

Apparently, THR has been able to boost its patient satisfaction scores by studying those recordings, but other than advising the customer service reps to be less robotic, there was not much discussion about how the patient experience was actually enhanced. Consolver did note that a systemwide decision was made to ask for a 50 percent payment upfront as opposed to 75 percent.

Phillips remarked that the "entire focus" of the recordings is to "improve our mission."

I visited THR's website, and a portion of its mission statement says "we recognize our values are rooted in God's Spirit and reflected in the human spirit."

I'm not a Christian, but I imagine if Jesus were asked that age-old rhetorical question of what he would do, might it include prioritizing the pressing for upfront payments and passive-aggressively withholding financial assistance?

I tried to revive my own spirit by asking around whether THR's approach was unique. Apparently it is not.

According to Marty Callahan, senior vice president of healthcare solutions at RevSpring, a Michigan-based hospital financing firm, if the bill is more than 4 percent of the patient's household income, it is highly likely to go into collections. In the THR patient's case, that means she would have to earn at least $100,000 a year--nearly double Texas' median household income--to handle her bill fairly comfortably.

"It often makes more financial sense to engage them," Callahan said. He brought up the same issue bouncing around my head while the THR recording was being played--the patient is either too intimidated or embarrassed to ask about financial options, and the provider could play a role in ameliorating those concerns.

By the way, THR does use at least one company that provides patient financing--San Diego-based ClearBalance. Its CEO, Mitch Patridge, was a little surprised at the scenario I shared with him. But, Patridge conceded that "different hospitals have different strategies." He added that some offer payment options, while others try to get as much upfront as possible.

I was told the same thing by Gayle Nelson, an attorney who is director of the hospital community benefits program at the Hilltop Institute at the University of Maryland in Baltimore.

Nelson said asking for upfront payments in the manner undertaken by THR is what is know as an ECA--that's short for "extraordinary collections action." Under new patient financial interaction guidance recently published by the Internal Revenue Service and the U.S. Treasury Department, such practices will be all but prohibited by the end of next year, according to Nelson.

That made me realize nothing is wrong with me--the system of healthcare finance in this country is just behind my own personal curve. Hopefully the people who are in charge of actually operating that system will play some catchup real soon. - Ron (@FierceHealth)

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Texas Health Resources uses phone call recordings to improve collections process