By Lola Butcher

MultiCare Health System is optimizing its patient access processes to meet the aggressive goal of collecting 2 to 3 percent of revenue at point of

As patients' out-of-pocket responsibilities continue to increase, point-of-service (POS) collections are becoming an important improvement initiative for many healthcare organizations.

Revenue cycle leaders at MultiCare Health System, a five-hospital system based in Tacoma, Wash., believe that informing patients promptly of their financial responsibilities can increase patient satisfaction. That is why the system rolled out a POS collections initiative at its hospitals in 2009 and expanded it to all MultiCare clinic locations and ancillary services within the year.

"We want to have these conversations while patients are in front of us so that they can ask questions and share concerns in person with our staff members as opposed to when patients are trying to decipher statements at home by themselves without the right people in the room," says Courtney Peterson, MultiCare's administrator of business operations.

The result of the 2009 program was an increase in revenue of $1 million per year as a result of the new POS strategies. The health system's ultimate goal is to collect between 2 percent and 3 percent of net revenue at the point of service while helping patients handle their financial responsibilities as easily as possible. MultiCare offers several patient-friendly services:

  • Financial counselors and Medicaid-eligibility vendors located at each hospital
  • Payment plans that allow monthly payments, interest free, for up to 12 months
  • A financial assistance program in which patients with incomes under 200 percent of the federal poverty level are covered at 100 percent
  • Prompt-pay discounts for self-pay patients, which give patients who pay within 30 days of the first statement a 40 percent discount off charges.

Training Frontline Staff

Every new member of MultiCare's hospital patient access staff and outpatient registration staff completes a three-hour class to learn about POS collections. "If our front-end registrars do not know or can't speak with confidence about what they are attempting to collect, our patients will notice that," Peterson says. "We want staff to feel comfortable and be able to break apart the patient's financial responsibility into multiple components."

A key element of that training is to educate staff members about why changes in the healthcare industry make POS collections a growing priority. "We want them to know that insurance companies and employers expect patients to take on greater financial responsibility," Peterson says. "We always tie it back to the patient and work to get our patient access staff to look at themselves as financial counselors."

MultiCare's patient access staff training also includes the following aspects:

Terminology. Staff members learn terms such as copay and deductible that are standard in the industry, as well as terms and services that are specific to MultiCare. For example, MultiCare uses the term "family billing" in which the bills for all family members are compiled in a single statement. Because patients frequently have questions about these bills, staff members must be able to explain which charges and patient liabilities correspond to which family members.

Policies. Patient access staff members need to know the payment options-such as prompt-pay discounts and monthly payment plans-that MultiCare offers. In addition, registration staff members need to be knowledgeable about financial resources, such as Medicaid, that may be available to patients.

Scripts. For example, a service recovery script is used when a patient resists paying money that is owed. All scripts are written to help patient access and registration staff members encourage patients to pay their bills. "We say 'How would you like to pay for that today?' as opposed to 'Would you like to pay for that today?'" Peterson says. "We find that a little change in words will have a different outcome."

Access sample scripts: Point of Service Collection Scripts

Knowing How Much to Ask For

The first step in a successful collection is being able to make an accurate estimate of what the patient will owe. MultiCare's pre-service center staff is responsible for preparing estimates for all scheduled patients. 

For straightforward cases, a pre-service center staff member uses payer websites to estimate the patient's liability. In complex situations, the pre-service center sends estimate requests to a dedicated inbox managed by MultiCare's revenue integrity team. The steps in the process are as follows:

  • Verify if any information?account number, payer, plan, current procedural terminology (CPT) codes or DRGs?is provided.
  • Use software to crosswalk CPT codes to ICD-9 procedure codes.
  • Identify the most likely DRG for the case.
  • Estimate average charges for that DRG.
  • Calculate the expected allowable charges.
  • Email the estimate to pre-service center staff within 24 to 48 hours.

Pre-service employees are responsible for informing patients of their estimated bills during the pre-registration telephone call and attempting to collect before the date of service. If staff members are unable to collect, the patient access technician asks for payment when the patient arrives for the appointment.

In addition to the estimated bill for the upcoming service, patients frequently may owe outstanding balances from previous visits. Patient access and outpatient registration staff are expected to look for prior balances and attempt to collect those when they interact with patients. 

Creating Accountability

MultiCare's POS collections took a big jump when the initiative launched in 2009, and they have increased revenue as a result of their POS strategies by more than $1 million each year since then, says Bethany Sexton, vice president of revenue cycle. She cites two success factors: setting collection targets for each unit and creating three tiers of accountability.

"Early in the process, there were accountability measures put in place for our patient access areas, but on the physician side of the house, there were never any targets," she says. "Outpatient patient access staff knew they were missing opportunities to collect copayments and other revenue, but they weren't sure how to pursue POS collections or how to set appropriate goals."

That changed when MultiCare established a system-wide target for POS collections that reflects historical data, the system's charity care and bad debt estimates, and best-practice benchmarks. The system-wide target is parsed into preliminary goals for individual departments.

Department heads receive an explanation of how the preliminary targets are determined and have an opportunity to identify any other factors that should be taken into account before the final targets are set for the year ahead. "Over time, we have recognized that there is no way we are going to get leaders engaged in this process if they feel like targets are simply being handed down from on high," Sexton says. "This has to be something that they are buying into by understanding how we are creating their department targets."

Each target has three levels of accountability:

  • Individual owner (for example, the clinic supervisor or a registration manager)
  • Director or administrator for the department
  • Vice president responsible for the division

MultiCare uses a dashboard to track how each department is performing relative to its monthly and annual collection targets and how the various units compare to one another. "This sort of reporting has given a lot of visibility to leaders across the organization and has enabled us to go back to directors, administrators, and vice presidents across the organization to bring their departments on board," Sexton says.

Optimizing POS Collections

An analysis of MultiCare's POS initiative earlier this year found that the system has potential to go beyond its current year-over-year improvements to increase revenue.

"We looked at all the departments that have a POS responsibility and noticed that about half of our POS leaders were not hitting their individual targets," Peterson says. "We can't expect our employees to see the importance of POS cash collections if we still have leaders in our organization who don't see the importance of it."

This prompted MultiCare to launch a process improvement initiative. The 35 departments that were not achieving their targets were categorized into five categories: inpatient, emergency department, ambulatory, ancillary, and clinics. This allowed patient access leaders to examine the barriers to success-and identify solutions-that fit specific types of work. "We didn't want a one-size-fits-all model because emergency department POS cash collections do not look like clinic cash collections," Peterson says. "We wanted to customize the program to the work that each department does."

Optimization activities included the following:

A survey sent to employees that have POS collection responsibilities. The survey sought to learn what employees like about the collection process, challenges and barriers to success, and the employees' confidence level with the tools available to them. "We also asked them how they want to be recognized for POS cash, knowing that there are a lot of areas that do a very good job," Peterson says.

Gemba walks. Peterson and other leaders went to underperforming departments to shadow employees and better understand what was working and what was not. A Lean management technique, Gemba walks take management to the front line to look for waste and opportunities for process improvement.

Development of POS bundles-or specific training modules-tailored to each department. "For example, when we went out to the emergency departments, we noticed that they were not using the scripts that they were trained to use," Peterson says. "So the emphasis for the emergency department POS bundle was around building confidence in using the scripts, rather than focusing on getting good patient cost estimates, which are difficult to calculate during emergency department registration. In contrast, the POS bundle for ancillary services focused on making good patient estimates.

The process improvement initiative has identified ways to make it easier for lagging departments to increase POS collections, giving Peterson confidence that the goal of at least 2 percent net revenue can be collected at the time of service. "We're making nice progress, but still we want to improve further," she says.

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

Quoted in this article (in order of appearance):

Courtney Peterson is administrator of business operations, MultiCare Health System, Tacoma, Wash., and a member of HFMA's Washington-Alaska Chapter (

Bethany Sexton is vice president of revenue cycle, MultiCare Health System, Tacoma, Wash., and a member of HFMA's Washington-Alaska Chapter (

Related resource:
HFMA's MAP is a web-based revenue cycle tool to improve fiscal performance, including point-of-service collections and patient communication processes.

Publication Date: Monday, November 26, 2012