St. Luke’s Cornwall Hospital increased point-of-service collections 220 percent and decreased patient wait times from 14 minutes to six minutes or less.


Two years ago, St. Luke’s Cornwall Hospital in Newburgh, New York, faced significant challenges related to patient access and collections for outpatient services.

As outpatient volumes for ambulatory and rehabilitation services rose for this 242-bed, not-for-profit system, processes for patient registration and patient financial services differed sharply from one site or service line to the next. The patient financial experience suffered because of these inconsistencies.

With 270,000 patients depending on the health system for care each year, the impacts of disjointed patient access and financial services processes for outpatient visits were substantial:

  • Cash collections were too low and too slow, and data analysis showed the potential to collect more than twice this amount with improved practices.
  • Benchmark data for key indicators of the patient experience were generally not captured, but it was clear that the patient registration process was too time consuming.
  • The hospital did not set point-of-service (POS) collection goals for staff at either the individual or group level.
  • Highly manual registration processes left data collection prone to errors that impacted the clean claims rate, resulting in payment delays.
  • Patients were frustrated with inaccurate or missing bill estimates, which led to high no-show and cancellation rates in various clinical departments.

Getting to the Heart of Patient Access

In April 2016, St. Luke’s embarked on a mission to revamp its patient access model to improve the patient financial experience, registration staff productivity, and patient collections. St. Luke’s established five goals for the initiative:

  • Increase collections, especially at POS.
  • Enhance patient satisfaction scores in the area of patient financial services to match the high levels of satisfaction with St. Luke’s clinical services.
  • Normalize the preregistration process for all outpatient departments.
  • Decrease registration wait times as well as no-shows and cancellations.
  • Collect and analyze data on patients who fail to meet appointments so that changes could be made based on the patterns shown.

Getting to the heart of patient access challenges took more than a technological fix. It also necessitated a change in culture and a high priority on data capture and analysis of key performance indicators (KPIs) that had not previously been measured. To ensure success, the leadership team executed a five-part strategy that exceeded expectations. Here’s how it was done.

Bringing Key Players on Board

St. Luke’s sought to achieve dramatic change—from Day One. Leaders believed it was very important that patients know from the start that patient access processes had been completely transformed with their needs in mind and would change their experience for the better.

To secure the culture change needed, St. Luke’s patient access and revenue cycle leaders gained buy-in from the top down. Once senior leaders understood and approved the initiative, St. Luke’s chose a partner consultant to design and implement a new patient-friendly pre-access system model. The focus of the redesign was to consolidate central scheduling, streamline workflows across departments, develop custom financial guidance and planning, and expand staff roles to cover registration and financial services responsibilities.

Meetings were held with both clinical and financial staff to design optimized workflows that allow patients to be financially cleared prior to hospital arrival. Onsite workshops focused on best practices for consolidating scheduling in preregistration authorization and combining admitting and financial counseling functions under one independent business owner for scheduled outpatient admissions.

With the new model defined, patient access and revenue cycle leaders held small-group sessions with referring physicians to explain the concept and the positive results the new model could generate for medical staff and their patients. Then, leaders introduced the model to staff.

For the transition to stick, staff needed to know that once the new model went live, there would be no going back. Leaders would only make a change if patient safety was at risk. Team members were expected to follow the automated workflows during each patient encounter knowing how their performance would be measured and shared with managers.

Web Extra: View St. Luke’s Cornwall Hospital pre-access workflow chart 

Developing Patient-Centric Financial Plans and Options

Leadership recognized that improving the patient financial experience required a new approach to financial services and counseling because each patient’s circumstances are unique.

Some patients may easily be able to afford their bills; others may welcome discussions around establishing payment plans before care is delivered to help relieve the weight of out-of-pocket costs. Data—such as predicting the likelihood patients will pay out-of-pocket balances—would be key.

Ensuring the new model would have the right team members in place was critical and required a different organizational structure with central scheduling and patient registration. The key was not to simply move people within the new organization. Instead, job descriptions were rewritten, with salaries adjusted to reflect higher levels of responsibility and increased attention to customer service. Then, central scheduling and patient registration staff were invited to apply for positions. Those who didn’t make the cut were offered positions elsewhere in the system.

Building Automated Systems With Best-Practice Workflows

Next, St. Luke’s collaborated with its consultant partner to implement people and technology systems to automate and streamline workflows specific to patient needs. Based on proven best practices for scheduling, registration, financial clearance, and customized payment planning, this new system and approach accomplishes the following:

  • Ensures that registrars follow common policies and procedures for scheduling, authorization of services, and financial clearance across departments.
  • Standardizes patient financial assessments using real-time data tools that verify benefits eligibility and patient demographic information and predict patient propensity to pay.
  • Estimates accurate patient out-of-pocket obligations, with real-time features that pinpoint the amount of patients’ deductibles met to date.
  • Offers payment plan options tailored to each patient’s budget and ability to pay.
  • Connects uninsured patients with financial assistance programs, when appropriate.

To boost patient satisfaction, St. Luke’s sought to improve patient access experiences by expanding pre-access service center hours to 14 hours per day—from 6 a.m. to 8 p.m.—up from 9 hours per day. Patients are offered a single phone number to call and, where possible, patient inquiries are handled by the same staff person throughout the individual patient’s journey.

Designing Pre-Access Registration Processes

With these goals in mind, St. Luke’s patient access, revenue cycle, and partner leadership designed a pre-access registration process that consists of just six steps:

  • Contact patients by phone at least five days prior to appointments.
  • Verify insurance information, deductibles, and copayments.
  • Run billing estimates.
  • Assess patient ability to pay using automated tools powered by real-time data.
  • Determine the most appropriate payment options and generate a customized financial care plan.
  • Preregister patients for all approved services.

A key element of the new pre-access model is to complete all or most of the process before the patient visit. Based on this process, patients arriving for care are segmented into three groups to reduce lobby wait times and appointment cancellations and speed patients to their clinical destination:

No-stop status: The patient has preregistered and is cleared to proceed directly to the patient care area upon arrival.

Quick-stop status: The patient has preregistered but has chosen to pay a copayment on the day of service rather than in advance.

Full-stop status: The patient must complete the entire six-step process before proceeding to the patient care area.

Developing Accountability and Continuous Improvement

To ensure adoption of pre-access procedures and staff accountability, managers and department leaders capture and monitor productivity reports that measure individual and team performance, including the following:

  • A daily activity report showing all transactions for that day.
  • A POS collections report, including missed opportunities
  • An eligibility report for both active and inactive eligibility results.
  • An open-tasks report utilized for registration quality, which identifies staff who are not closing open items in a timely manner.
  • A bill-estimation report, which shows an estimation for patient responsibility and payments at a glance.
  • Phone reports that identify all phone-related activities containing wait times and abandon calls.

Moving Forward

St. Luke’s achieved immediate transformation—and the results exceeded leaders’ expectations:

  • Monthly point-of-service collections quickly surpassed the system’s monthly goal, with a 220 percent increase in POS collections within two years.
  • Patient wait times have decreased from 16 minutes to less than six minutes for full-stop patients, three minutes for quick-stop patients, and zero minutes for no-stop patients.
  • Seventy percent of scheduled appointments do not experience wait times.

Today, 80 percent of St. Luke’s patients are no-stop or quick-stop patients. Even better, appointment no-shows and cancellations have decreased dramatically.

Results of St. Luke’s Patient Access Transformation Initiative
St. Luke’s achieved immediate transformation—and the results exceeded leaders’ expectations.

Sharing Lessons Learned

How can your organization support a better patient access experience while boosting point-of-service collections? St. Luke’s experience points to four lessons learned.

Gain support from the top down. It’s critical that C-suite leaders understand that implementing a model like this isn’t just an opportunity to enhance patient collections. The processes and technologies that fuel this model are proven to increase patient engagement and improve satisfaction from POS—and at each point in the patient’s journey.

Invest in education for patients, staff, nurses, and physicians. St. Luke’s marketing team used patient statements as one opportunity for education, with material included in each billing statement that described the new model and provided a phone number for patients to call with questions. Signage and leaflets also explained the change to patients, staff, nurses, and physicians on site. Meanwhile, St. Luke’s invested in multiple training sessions for staff, with leaders acting as coaches throughout preimplementation and go-live.

Define metrics for success, capture data to support them, and make performance results highly visible. Before the initiative, staff knew what KPIs St. Luke’s would measure and how performance would be communicated to individuals and to the team.

Reward employees for high performance. Employee morale is high when employees have the tools and training to succeed. At St. Luke’s, celebrations acknowledge employees’ hard work and show them the value of transformation—not just from the point of view of the organization, but from patients’ perspectives as well.

As St. Luke’s experience shows, standardizing patient access workflows while personalizing the approach to patient financial services can dramatically improve an organization’s financial health and strengthen its ability to fulfill its mission.


Jill Barton is vice president, revenue cycle, St. Luke’s Cornwall Hospital, Newburgh, New York, and a member of HFMA’s Hudson Valley New York Chapter.

David Shelton is CEO, PatientMatters, LLC, Orlando, Florida, and a member of HFMA’s Lone Star Chapter.

Publication Date: Friday, November 02, 2018