Collecting co-pays at the ED registration desk.

Dixielee, BSN, RN · May 28, 2005

Our facility is suggesting that we start collecting co-pays on insurances at the ED registration desk upon discharge. I am completely against this... Any feedback out there?

Why are you against this? Do you have to pay at the grocery store, your favorite eatery etc when you check out? What is the difference? Your patient will have already received care, so there is no EMTALA/COBRA violation. IF they can not pay, they will be billed or other arrangements made. They are not going to throw them into debtors prison if they cannot pay.

Anyone who is truly indigent can sign up for medicaid at this time. People who are responsible and are going to pay their bills are going to pay them weather they are asked for it at discharge or sent bills. This is just an effort for hospitals to get their payments a little sooner rather than later.

In case you haven't noticed, there are tremendous numbers of non payors coming thru the ER doors. Many are uninsured poor, or illegal immigrants. You can probably never expect to see much or any money from them. Why not set up a system to at least try to get something back for services rendered.

Every hospital ER I have worked in since about 1999 has been doing this, and I certainly don't see a problem. No one is denied care, no one is harrassed, no one is turned away. If hospitals do not bring in some money, we will all be unemployed someday.

LydiaNN · May 28, 2005

Is it that you're upset that people are expected to pay, or that you are expected to find timeto manage this task among all the others that you are expected to handle? In the case of the former, it doesn't seem like a big deal. Certainly not unheard of, anyway. In the case of the latter, it doesn't seem like a very good use of nurses' time. I hope they are scheduling extra staff in light of the newly increased duties.

Dixielee, BSN, RN · May 28, 2005

I have never seen nurses have to do this task. Either there is a discharge window that all patients have to go by or there are financial counselors who see the patients before they leave the building. Nurses have nothing to do with billing, collection or filing of any kind. We do what we always have done.

Currently I work in a locked ED with only one door unlocked from the inside for general exits. There is a big red sign that reads Discharge Window and it is manned 24 hours a day. Every patient stops there and options are reviewed at that time. They are told that their insurance requires a co pay of $$ amount and would they like to pay at that time. All others are asked if they would like to pay something on their bill or make other arrangements. I have never even had anyone complain. At least you get your health care before having to pay, unlike gasoline where you have to pay up front.

austin heart, BSN, RN · May 29, 2005

I have never seen nurses have to do this task. Either there is a discharge window that all patients have to go by or there are financial counselors who see the patients before they leave the building. Nurses have nothing to do with billing, collection or filing of any kind. We do what we always have done.
Currently I work in a locked ED with only one door unlocked from the inside for general exits. There is a big red sign that reads Discharge Window and it is manned 24 hours a day. Every patient stops there and options are reviewed at that time. They are told that their insurance requireds a co pay of $$ amount and would they like to pay at that time. All others are asked if they would like to pay something on their bill or make other arrangements. I have never even had anyone complain. At least you get your health care before having to pay, unlike gasoline where you have to pay up front.

Ditto all she said in our ER.

TlhRNED · May 29, 2005

I have never seen nurses have to do this task. Either there is a discharge window that all patients have to go by or there are financial counselors who see the patients before they leave the building. Nurses have nothing to do with billing, collection or filing of any kind. We do what we always have done.
Currently I work in a locked ED with only one door unlocked from the inside for general exits. There is a big red sign that reads Discharge Window and it is manned 24 hours a day. Every patient stops there and options are reviewed at that time. They are told that their insurance requires a co pay of $$ amount and would they like to pay at that time. All others are asked if they would like to pay something on their bill or make other arrangements. I have never even had anyone complain. At least you get your health care before having to pay, unlike gasoline where you have to pay up front.

We are not a locked down unit- we have entrances and exits at both sides of the ED, there will not be any added staff, we are already fighting for staff, and we are not a grocery store.

Dixielee, BSN, RN · May 29, 2005

We are not a locked down unit- we have entrances and exits at both sides of the ED, there will not be any added staff, we are already fighting for staff, and we are not a grocery store.

I was not implying that you were a grocery store. Don't be so defensive. You asked for feedback and you did not give any other information for us to form an opinion. I was just telling you how I have seen it in other ER's, so lighten up.

You implied you did not like the idea of collecting money...period. You never mentioned staffing issues or any thing else. If it is impossible for you to do it, then don't consider it. It will only work if you have someone to do it. If you can't do it, just continue as you always have. If you have the option of mentioning to patients that they may need to stop by the clerks desk or whoever would do it, then ask, but that doesn't mean they will stop. If I were in your ER and wanted to pay a copay, would there be someone to accept it, or would it put a further drain on your resources? Just looking at options. You know your situation, we don't.

LydiaNN · May 29, 2005

I was not implying that you were a grocery store. Don't be so defensive. You asked for feedback and you did not give any other information for us to form an opinion. I was just telling you how I have seen it in other ER's, so lighten up.
You implied you did not like the idea of collecting money...period. You never mentioned staffing issues or any thing else. If it is impossible for you to do it, then don't consider it. It will only work if you have someone to do it. If you can't do it, just continue as you always have. If you have the option of mentioning to patients that they may need to stop by the clerks desk or whoever would do it, then ask, but that doesn't mean they will stop. If I were in your ER and wanted to pay a copay, would there be someone to accept it, or would it put a further drain on your resources? Just looking at options. You know your situation, we don't.

And yet when I asked her for clarification, since I sensed there was more going on, you shot my thoughts down with "I've never seen it done that way", something to that effect. Neither have I, but given that the idea was clearly bothering her, and assuming that there must be a reason for that, I looked for a further explanation.

palesarah · May 29, 2005

I guess it's all in the way it's handled... a few years back, when I was in nursing school, I was assaulted in the parking lot of my workplace (not a hospital) and since I had been hit in the head, my boss brought me to the ER to get checked out. I felt OK but I had been hit pretty hard in the head, twice, so I went. On discharge, I was not asked if I would like to pay my copay or part of it and be billed for the rest, I was told by the rather abrasive lady at the discharge desk that my insurance had a copay and how would I be paying it today?

I was in nursing school, working part time, we were on a really strict budget- I had a credit card I carried for emergencies, and I used it. (And I was a little po'd at my boss for dragging me to the ER instead of sending me home where I could see my regular doctor without the gaint copay, but hey, I don't work for her anymore)

Anyway, my point is, I can see how tense situations could arise in these billing situations and why some people may not be eager to see it implemented.

student4ever · May 29, 2005

I guess it's all in the way it's handled... a few years back, when I was in nursing school, I was assaulted in the parking lot of my workplace (not a hospital) and since I had been hit in the head, my boss brought me to the ER to get checked out. I felt OK but I had been hit pretty hard in the head, twice, so I went. On discharge, I was not asked if I would like to pay my copay or part of it and be billed for the rest, I was told by the rather abrasive lady at the discharge desk that my insurance had a copay and how would I be paying it today?
I was in nursing school, working part time, we were on a really strict budget- I had a credit card I carried for emergencies, and I used it. (And I was a little po'd at my boss for dragging me to the ER instead of sending me home where I could see my regular doctor without the gaint copay, but hey, I don't work for her anymore)
Anyway, my point is, I can see how tense situations could arise in these billing situations and why some people may not be eager to see it implemented.

I totally agree with that. I currently work in registration in a small but very busy ER, and we don't take any co-pay or any other kind of payment up front. This is because there are many complex issues (besides people forgetting to bring their wallet with them to the ER when bleeding profusely) to consider. First of all, until everything goes through billing, there is no way to tell how much the bill is going to be in order to set up payment plans, etc. Second, if a patient has insurance but does not have their card, we cannot bill that insurance until we have the information, therefore until they call us back, they are a self-pay. How are we supposed to know if their insurance has an ER copay or not! Also, collecting co-pays at the time of discharge would create a need for us to learn what the co-pays are on ALL insurances, because we can bill the insurance if we have their insurance in the computer system already, but without the card in our hand, it would be impossible to know what co-pay to charge!!!! Not to mention that when a patient comes in from an MVA, a lot of times they are self-pay so that they can submit the bills to the responsible auto insurance - why would they need to make a co-pay??? OR, they are undecided as to whether to bill medical insurance or auto insurance, so the situation may change. And for the suggestion of having people apply for medicaid at time of discharge - well, that would have the registration clerks needing to learn a whole new job and do that all the while trying to keep up with the patients coming in, the admissions needing extra signatures/information before being taken to the floor, entering that all into the computer, taking care of the paperwork that's coming back from the discharged patients - all of that at the same time!!! That is an impossible task, from someone who knows what it's like to work as the only clerk in an ED Registration dept (the graveyard shift has only one clerk - little old me!). From what I understood from the OPs post, in her situation there is barely enough staff to do the registration tasks they already have, and there will not be an increase in staff. However, to implement this kind of plan would require quite a bit more training - to understand how the business office works through billing, as well as payment plans, not to mention the medicaid specialist's job to take new applications for medicaid. Our hospital does strictly billing - nothing is accepted up front. This makes it possible for us to concentrate solely on patient care, and then the business office handles billing and payments. They will go so far as to take non-payers to court for the money owed if they don't pay their bills. This way patients get the care they need, and we (Registration) stay sane enough to do our job. To the OP, if your administration is seriously considering having you implement this practice, let them know that you will need several new staff members to do this entirely huge new task, and if they don't want you to hire anybody new, then they can come down and do the job, because your clerks don't have the time! That's just my opinion and what I would say to them, but it seems like we're from similar situations. Thank God our hospital's administration has not suggested such a preposterous idea!

mommatrauma, RN · May 29, 2005

We do it...If you have the money you pay, if not, you're billed..works out fine...Haven't heard any complaints...

pkapple · May 29, 2005

I work at a very rural ed. We have an admission clerk so to speak until 11pm. After 11p, we check them in on paper forms, copy id and insurance cards, triage, treat, medicate, transfer or discharge. I do not have every insurance rate, I don't even have the computer up, but I can read an insurance card that says ER COPAY 100. If I am not in the middle of a crisis I will ask the patient if they are paying the co-pay, if they have no insurance, I have them sign a promissary note for 25 a month til this visit is pd in full.

I don't ask up front, it is part of the discharge after 11p, when admission clerk is on I ask them to check with her---we don't chase any one down or threaten to lock them up. If being asked to pay your co payment offends anyone-I'm sorry, but I would hope people have some idea of how their insurance works. My husband had a heart cath in January, I am still paying off the copay of 20% which with our 500 deductible(being Jan) amounted to over 2600 bucks. I knew we would have to pay but was a bit surprised at the amount, nevertheless, I am making payments.