The health system added an order set—“consult to financial counseling”—in the electronic health record “ED quick list.”


In recent years, it’s become one of the biggest trends in patient-friendly communications: Informing patients up front about the estimated cost of healthcare services and offering options—payment plans, financial assistance, or access to insurance coverage, depending on their situation—to help them address their financial responsibilities.

Those practices allow patients to understand the estimated out-of-pocket costs of scheduled services and determine how they will manage their healthcare financial responsibilities. In some cases, just knowing the estimated cost reassures patients that their costs will be manageable; in other situations, setting up payment plans or applying for financial assistance provides peace of mind.

But that proactive communication does not apply in fast-paced emergency departments (ED) where timeliness takes precedence over financial matters. Patients are typically treated and admitted to the hospital or released with an order to seek follow-up care from an outpatient provider. But they do not know how much they owe until the bill arrives a few weeks later.

That lack of transparency prompts many ED patients to worry about the financial consequences of the care they are receiving, says Nicholas Gavin, MD, ED chief of service at NYU Langone Hospital-Brooklyn. And physicians have no way to alleviate their concerns. “I can’t tell you if your ED visit is going to result in $10,000 worth of bills or $200—I can’t even approximate it,” he says. “There is discomfort in that.”

To address that discomfort, he worked with the health system’s revenue cycle team to connect ED patients proactively with financial counselors. 

Patient Friendly in the ED

Like clinicians everywhere, Gavin has noticed more patients worried about healthcare costs, largely because of high-deductible health plans or lack of insurance coverage.

“Our mandate from our leadership has been that we should be reducing their out-of-pocket costs as much as possible,” Gavin says.

Options for doing so include the following:

  • Helping patients obtain Medicaid coverage
  • Helping patients gain insurance coverage through the state marketplace
  • Making financial assistance available to reduce patients’ out-of-pocket responsibilities

“At our hospital, we have a very generous financial assistance program that a lot of patients don’t know anything about,” Gavin says, referring to a policy that offers a 100 percent discount to families with income up to 600 percent of the Federal Poverty Level (FPL) and smaller discounts available to families with income up to 800 percent of FPL.

Signs posted in the ED notify patients that financial help is available, but patients and family members dealing with a medical emergency are often too distracted to take in the information. Furthermore, when they return home to recuperate, patients may not have the energy to initiate contact with the hospital’s financial counselors when they do not yet know how much they will owe.

When he heard patients express concerns about their ability to pay medical bills, Gavin worried that they would not seek recommended follow-up care because they were stressed about the pending bill for ED care. He thought that stress could be alleviated if financial counselors proactively reached out to offer help.

“We really wanted to change the dynamic from a passive situation that’s totally patient-dependent to become patient advocates who make sure our team does what we can to reduce a patient’s out-of-pocket expenses,” he says.

Order Through the EHR

In October 2014, NYU Langone added an order set—“consult to financial counseling”—in the electronic health record (EHR) “ED quick list.” “It’s a simple one-click to sign an order that populates a work queue for our financial counselors,” Gavin says.

In response to those orders, financial counselors will contact patients typically within 24 hours and always within 48 hours, says Sean McAleer, senior director of revenue cycle operations, NYU Langone Health.

“We know that patients are more willing to confide in a doctor than a registrar, so they approach the discussion very sensitively,” McAleer says. “They indicate that the patient had a conversation with the ED physician, and they understand there may be some concern about their bill or their out-of-pocket expenses.”

The program is offering relief. In the 19 months ending July 2017, the emergency physicians issued orders for financial counseling for a total of 426 patients and 60 of them received financial assistance covering their entire bill, while two others received smaller discounts. Other successes include the following: 

  • Adequate insurance was found for 87 patients
  • 12 patients were approved for Medicaid
  • 48 patients set up payment plans

Another 89 patients sought financial assistance but later withdrew their applications, and 87 did not cooperate with the Medicaid application process. The reasons are unknown. Gavin and McAleer speculate that, in some cases, when patients learned what their actual out-of-pocket responsibility was, they realized they could pay it without assistance. Others may have been unwilling to provide the information required for financial assistance or Medicaid applications.

The Bottom Line 

In the fiscal year that ended Aug. 31, the health system provided $520,504 in financial assistance to patients served through the ED referral order process.

Considering the industry’s post-service self-pay collection rate is about 25 percent, McAleer estimates that those patients would have paid about $130,000 if not for the referrals to financial counseling. Likewise, he estimates that about 75 percent of those patients’ balances would have eventually been written off as bad debt. Thus, the program resulted in an estimated $390,000 reduction in bad debt in the most recent fiscal year.

Physician Coaching

Considering that more than 65,000 patients are treated in NYU Langone-Brooklyn’s ED each year, physicians are ordering financial counseling outreach for a small portion of the patients that likely would benefit from the support.

That does not reflect resistance on physicians’ part, Gavin says. “I think physicians generally like having the ability to advocate for their patients in a simple way,” he says.

Rather, the order for financial counseling is only made when patients tell doctors something to the effect of “I’m worried about my ability to pay for this,” or “I’d rather sign out against medical advice than be admitted to the hospital” because of financial concerns.

Physicians are trained to tell patients that, although they are unable to estimate what the cost of the care will be, they will ask a financial counselor to contact them quickly. Says Gavin: “They are coached to say, “We are going to put you in touch with someone who can help you through that process. There are generous financial assistance programs. We’ll make sure that any out-of-pocket costs are minimized. But, this is about your health. We need to focus on your health right now, and this is the right thing to do.”

Lessons learned. Busy emergency physicians need to be reminded that entering orders for financial counseling consults can make important differences to patients they are treating. “What they find validating is seeing that, when we do referrals, X number of patients get assistance or Medicaid,” Gavin says.

Financial Counseling in the ED

When NYU Langone opens a new hospital currently under construction, McAleer hopes that the ED will be large enough to accommodate onsite financial counselors to offer on-the-spot assistance.

When that is not feasible, creating an EHR order set that allows emergency physicians to request that financial counselors proactively contact patients who are concerned about the cost of care can be an effective strategy. 


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

Interviewed for this article:

Nicholas Gavin, MD, is chief of service, emergency department, NYU Langone Hospital-Brooklyn, Brooklyn, N.Y. 

Sean McAleer is senior director of revenue cycle operations for NYU Langone Health and a member of HFMA’s Metropolitan New York Chapter.

Publication Date: Thursday, September 14, 2017