Teaching patients to expect financial communications from front-desk staff helped Aspen Valley Hospital increase upfront collections.


A multi-pronged approach allowed Aspen Valley Hospital, a 25-bed critical access hospital with two outpatient locations, to more than double its front-desk collections over a six-year period. Building on that success, the hospital introduced technology that increased overall collections by 140 percent and online collections by 33 percent between 2007 and 2013.

Younger money is better money,” says Debby Essex, Aspen Valley’s director of admissions. She attributes Aspen Valley’s success to the organization’s commitment to three goals: encourage patients to make point-of-service payments, reward staff for collecting money, and help patients understand their financial obligations before services are performed.

Offering Prompt-Pay Discounts

During ski season, Aspen Valley operates an urgent care clinic in Snowmass Village to serve skiers and other tourists visiting the community. Historically, the hospital’s slow credit card-reading technology and the ability to accept payments in just a few locations discouraged patients from paying at the time of service.

In addition, collecting from tourists after discharge often proved difficult. “When you have patients coming from Australia, Brazil, South America, England and other places, it makes it cumbersome to try to collect,” Essex says.

Aspen Valley took two steps to encourage immediate payment. The organization installed payment card devices on all computers, and it introduced a 20 percent prompt-pay discount on the self-pay responsibility for patients who pay their bills in full at the time of service.

Lesson learned: Both patient-friendly strategies encourage patients to pay upfront. “If somebody saw us fumbling around, they would say, ‘Just forget it. Send me a bill,’” Essex says. “But if it is clear that I know the amount that you owe, I’m ready for your card, and I’m offering you 20 percent off, patients are going to take advantage of that because it is easy.”

Creating a Staff Incentive Program

Aspen Valley leaders also wanted to improve collection practices at the hospital. Like their peers at many other hospitals, Aspen Valley’s front-desk staff were initially reluctant to ask patients for money when they came for their appointments. A financial incentive program that encourages staff members to work together to increase collections changed that.

Everyone in the department shares a financial bonus if the staff as a whole meets or exceeds the quarterly goal, which is set by Aspen Valley’s director admissions (Debby Essex) and CFO Terry Collins. Essex’s department includes schedulers, precertification staff, admissions staff, and billing staff. Everyone who works on patient accounts is eligible for a bonus, and the staff compete with each other to see who can collect the most.

Essex circulates a daily report that shows how much each staff person collected on the previous day and their month-to-date collection totals. That report, which also goes to the CFO, creates peer pressure that encourages good performance.

“The front desk can’t collect unless the scheduler schedules the appointment, and the front desk can’t collect unless the precertification staff has calculated the estimate of the patient charges,” she says. “So if the front desk isn’t collecting money, the scheduler will say, ‘I set up that account. What happened?’ And then the precertification person will say, ‘I notated the $100 the patient will owe. Why didn’t you collect it?’”

A quarterly 5 percent bonus is distributed among all department members based on the number of hours they worked during the quarter.

The result: Upfront collections increased 140 percent between 2007 and 2013.

Lesson learned: Initially, Essex reported the total collections for all front-desk staff as a group, which gave poor performers room to hide. “I had one or two people who weren’t talking to patients about their bills or collecting,” she says. “So I decided that everybody should know where everybody else is every day.”

Setting Patient Expectations

Not surprisingly, patients were taken aback when hospital staff first started asking them for money at the point of service. In team meetings, staff members reported the pushback: Patients said they had previously not been asked for money from the hospital or that another member of the registration team never asked for money.

“So I said, ‘Every one of you has to ask every person every time—or at least talk about the money involved with their account—because we have to create an expectation that we’re going to talk about money,” Essex says. “Even if we are not expecting to collect anything, we can say, ‘We ran the benefits on your account. Your procedure should be covered 100 percent. It doesn’t look like you owe anything today.’”

The day-of-service conversations go the smoothest when patients have been notified about their financial responsibilities before they arrive, Essex says. A financial counselor calls each patient several days before a scheduled service. “We say, ‘We have contacted your insurance company, and I was able to get your benefits. Because your benefits are X, Y, and Z, we are expecting your self-pay portion next Tuesday to be $500,’” Essex says.

Lesson learned: It didn’t take long for the financial incentive—and the friendly competition within the hospital—to influence staff attitudes. Registration staff started telling patients about the competition and asking for their help in “winning.” Essex hears people in the community say things like, “When I come in, I’m going to pay ‘Jane’,” or “I forgot my wallet but I’m going to call ‘Jane’ with my credit card because she’s trying to make her goal.”
“Once we made it fun, everybody kind of got into it,” she says. “Now our hospital employees who owe money tend to pay the front desk right away because they want someone to get credit for it.”

Facilitating Payments at Discharge

Aspen Valley uses a payment mobile app designed specifically for health care that allows quick and secure patient collections throughout the hospital using an iPad. The mobile cart used for bedside registration in the emergency department (ED) includes a card-swiper. ““We develop an estimate the same way we would have done if the patient was scheduled,” Essex says. “Then the registration staff member shows the patient the bill, swipes the card, and emails the receipt,” Essex says.

If patients are admitted to the hospital without an opportunity to pay upfront—for example, a person who is injured and goes directly to surgery—hospital staff use an iPad to facilitate credit card payments at the bedside as part of the discharge process. Until the mobile app was available, hospital staff members were hesitant to ask patients for payment at discharge because it required them to take a credit card from the inpatient room to the registration office for processing.

Lesson learned: “We try to make sure patients understand their benefits,” Essex says. “For example, staff members say, ‘Because you were an inpatient, this is what your insurance is telling us. You have a $5,000 deductible and 20 percent coinsurance and that equals this dollar amount. If you’d like to pay today, we can offer you a 20 percent discount. If you want to set up a payment plan, we don’t offer the 20 percent, but we can set that up for you right now. That way, when you go home you don’t have to think about any of this again.’”

Making Post-Discharge Payments Easy

For patients who do not pay their bills at the time of service, Aspen Valley seeks to make post-discharge payment as convenient as possible. The hospital embedded a patient portal on its website in 2010 and saw online payments take off. From 2011 to 2013, the online hospital collections increased 33 percent.

When patients are discharged from the ED or the after-hours clinic, they receive a “billing roadmap” that illustrates the billing process and informs patients why they will receive multiple bills—for example, radiology reads are billed separately—for the care they received. The roadmap document gives information about how to pay online or contact the hospital billing department by phone or email.

Access related tool: Aspen’s Billing Roadmap

“We try to include every possible way to communicate with us on one piece of paper. We often don’t know whether our patients (many who are tourists to the area) will be leaving, so we want to make it easy for them to reach us in whatever way works for them,” Essex says.

Lesson learned: Aspen Valley’s roadmaps include photographs, phone numbers, and email addresses for three financial counselors with the message, “We understand hospital bills can be confusing. If you have questions, please don’t hesitate to contact us.” While that reinforces the hospital’s patient-friendly approach, Essex will avoid using individual staff member names on future printings. When staff members change, the contact information is no longer appropriate, which can be confusing.

Changing with the Times

As hospitals seek to increase point-of-service collections, they must use new processes and protocols to support that priority, Essex says.

“The key for us was the CFO’s buy-in to start a bonus program and the recognition that front-end collections really make a difference,” she says. “The other key is technology that is easy to use. It has to be easy for staff to collect.”


Lola Butcher is a freelance writer and editor based in Missouri.

Debby Essex is director of admissions at Aspen Valley Hospital, Aspen, Colo., and a member of HFMA’s Colorado Chapter.

Publication Date: Tuesday, July 15, 2014