Financial Counseling

Building Patient Relationships Through the Revenue Cycle

January 20, 2017 5:31 pm

Providence Health & Services uses proactive financial counseling and compassionate processes to keep bad debt and financial assistance levels lower than national average.

Patient-friendly revenue cycle practices used by Providence Health & Services, a 34-hospital system based in Renton Wash., caught the eye of the federal government this year when the Department of Health & Human Services selected Providence to serve on its advisory panel for simplified medical billing solutions.  

“It has always been our philosophy that the entire revenue cycle process is an ongoing relationship with the patient,” says Teresa Spalding, vice president of revenue cycle with Providence. “We believe every person wants to resolve their bills, and it’s our responsibility to help them figure out how to.”

Providence, which serves more than 3 million patients each year, has bragging rights on two key revenue cycle metrics. Despite serving markets in which more than 50 percent of patients are covered by Medicare or Medicaid, the system’s bad debt is less than 1 percent of revenues and financial assistance is typically in the range of 3 percent. That is possible because the system finds a payer source for so many of its patients.

Because revenue cycle staff are typically the first and last touch points that a patient has with Providence, Spalding sees revenue cycle functions as a “wraparound” of the patient experience. Success starts with up-front financial counseling and ends with a customer service contact center in which staff are trained to find ways to address patients’ unique circumstances.

“This is something we consider when scoring our customer service calls,” says Kathryne Rouse, system director, revenue cycle, customer support. “We ask: if the patient were to have healthcare needs in the future, based on their last experience with us, would they choose to come back to Providence? And we always want that answer to be “Yes.”

Proactive Financial Counseling

Typically, financial counselors are part of health systems’ patient access units. But at Providence, they are part of the customer support team, focused on finding coverage up front, so patient responsibility is as minimal as possible.

“We start supporting patients at the point a clinic visit is scheduled,” Spalding says. “We do not wait until an inpatient stay is needed or until after they are discharged. We try to proactively create a relationship with the person before they receive care.”

Outpatient protocol. Providence clinics are supported by a centralized financial counseling team. If patients are unable to pay their copayments, coinsurance or deposits, or they don’t have insurance coverage, clinic staff can connect them to financial counselors to arrange payment plans, screen for financial assistance eligibility, or search for payer sources.

“They transfer that person to our centralized clinic financial counseling team in real time, and we essentially do the full financial counseling work over the phone for the clinics,” Rouse says. “That has worked incredibly well.”

Providence operates 600 physician clinics. The clinics that fully use the centralized financial counseling have seen an increase in insured revenue, a decrease in bad debt, and fewer no-shows.

“If you talk to your patient before their appointment and put them at ease about the bill, they are more apt to show up,” Rouse says. “We’ve seen an increase in up-front payment because the patients who can’t pay the full amount feel good about putting something toward their visit.”

Inpatient approach. Financial counselors are located at each hospital, and all are certified application assistors. If patients express concern about their medical bills, financial counselors help them to find alternative funding or coverage sources such as third-party liability insurance; social security disability insurance; coverage via a health exchange; Medicaid; or financial assistance from Providence.

“The financial counselors make sure they visit those patients, put them at ease and help them find alternative coverage sources,” Rouse says. “We want to make sure our patients are focused on their care and getting well again and not worrying about their finances.”

Measuring success. Among other things, financial counselors are measured on sponsorship, meaning converting uninsured accounts to insured and sponsored accounts. In 2016, Providence financial counselors have found payer sources for more than 42 percent of uninsured patients, Rouse says.

Patient-Friendly Billing Practices

Providence uses four billing practices that consumers appreciate, Spalding says.

Family billing. All members of a household can be billed as a single guarantor account.

Consistent billing. Bills for physician services, hospital services, and home services appear on a single statement, and all administrative processes are the same, regardless of where the bill originates. “Insurance billing and follow-up use the same processes and time frames so it is consistent for the patient,” Spalding says. “When we do a charity care determination, it automatically applies to all services across Providence.”

Flexible, interest-free payment plans. Each patient’s circumstances are different, and payment plans need to reflect that, Rouse says. “We might set someone up for a small payment for six months or even a year while they are paying off all their other bills. This may mean we adjust their payment plan three or four times,” she says.

Multiple contact attempts before giving up. Providence sends three statements, a pre-collection letter, and makes at least two outbound calls to patients before sending their accounts to collections. “Many healthcare systems will automatically send their accounts to collections,” Rouse says. “This is not something we will do. Our commitment at Providence is to always attempt to reach the patient and work with them first.”

Consumer-Oriented Call Center

Providence’s Portland-based customer service center serves all its hospitals and clinics, handling approximately 100,000 incoming calls and 100,000 outbound calls each month. The staff includes approximately 100 inbound agents, approximately 50 account-resolution specialists making outbound calls to self-pay patients, financial counselors, and a training/quality assurance team.

The health system’s promise to patients— is posted on the walls: “Together, we answer the call of every person we serve: Know me, care for me, ease my way.”

“And that is really built into how we train and empower our employees or, as we like to call them at Providence, ‘caregivers,’” Rouse says.

Patient-friendly features include the following.

Staffing to minimize hold times for inbound callers. Providence uses a workforce management tool to identify patterns in call volumes. “It helps us build a staffing model so we are adequately staffed when patients are calling,” Rouse says.

Extended hours. The call center operates from 7 a.m. to 7 p.m., Monday through Friday to accommodate consumers who want to call about their bills before work hours or in the evenings.

Call monitoring. Inbound calls are randomly monitored and recorded for quality assurance purposes; 100 percent of outbound self-pay calls are recorded. Quality assurance staff listen to calls and score staff on their performance. “The focus of those scorecards is around the patient’s experience,” Rouse says. “That includes the tone. Did we call them by name? Did we say please and thank you? And did we answer the question or resolve the reason for the call? If it is a collection call, did we resolve the account? If a patient expresses an inability to pay or a hardship, did we offer them payment plan options or determine a need for financial assistance?”

The first priority for customer service contact center staff is providing excellent customer service; if patients express concern, the priority then becomes figuring out how to help them address their concerns.

“We expect Providence customer support caregivers to feel empowered to always do the right thing for our patients, and to ease their way through the process,” Rouse says. “Every person has an individual story and circumstance, and we want to be sensitive to that.”


For example, call center staff are trained to process some accounts for charity care rather than attempt collection or designate them as bad debt. When possible, patients are also directed to financial counseling for help with applying for Medicaid or other services. “We only want to collect from patients that have the ability to pay,” she says. “If we can identify a reason for the account to qualify for financial assistance legitimately, that is where we would rather see that account go to avoid creating an unnecessary hardship for a patient.”

On-the-spot screening for financial assistance. If patients who owe $1,000 or less express financial hardship, call center staff used to suggest that they apply for financial assistance, Rouse says. Staff are now trained to verbally screen those patients for financial assistance eligibility over the phone.

“We have streamlined that process to make it more efficient and really help our patients to focus on healing at home and not stressing about their bills,” she says.

Staff use a screening process that captures information such as total amount owed to Providence; number of people in the household; total monthly household income; and an estimate of other expenses. This process determines if the family is eligible for assistance.


“If they qualify, then we do a one-time financial assistance write-off automatically,” she says.

Customer-service discount. If patients express concerns about their experiences, customer contact center staff are empowered to make their concerns right. “Our customer service contact center staff have the ability to give discounts on balances because we did not meet patients’ expectations,” Spalding says. “It gives our customer reps confidence and empowerment that they can resolve issues so that patients are delighted that we listened and cared, and took action on the spot,” she says.

These adjustments are routinely audited. “We want to make sure staff are adjusting accounts appropriately.” Spalding says. “Staff receive coaching to determine appropriate discount levels.”

Monitoring patient experiences. Customer service contact center staff log every good or bad comment patients make about their overall experiences with Providence. At the end of calls, staff use account activity codes to indicate the main reasons people call. A quality assurance or customer service leader then reviews call logs and captures data to identify improvement opportunities.

For example, if the quality assurance specialist is reviewing calls coded “didn’t understand charges,” the specialist can view the account to see specifically what the person did not understand and the explanation provided by staff.

“Then the quality assurance specialist considers, ‘Do we need to change our statements? Can we develop written materials that we can share with consumers? Do we need to train our customer service specialists better? Is there something not printing on our statements the way it should, so that instead of our patient-friendly language it is printing in computer language?’” Spalding says. “We are constantly analyzing why patients are calling, then taking action to resolve and improve the root cause.”

In addition, customer service contact center staff create monthly reports for each hospital and clinic to describe why patients are calling, the concerns they expressed, and the compliments they gave.

A Holistic Approach

Providence’s patient-friendly approach combines proactive payment and financial assistance policies with empowering call center staff to assist patients. This holistic approach builds strong relationships with patients while reducing bad debt and helping patients fulfill their financial responsibilities.

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

Interviewed for this article:
Kathryne Rouse is system director, revenue cycle, customer support, Providence Health & Services, Portland, Ore., and is a member of HFMA’s Oregon Chapter.

Teresa Spalding was vice president, revenue cycle, Providence Health & Services, Renton, Wash., until she retired from Providence at the end of 2016. She is a member of HFMA’s Washington-Alaska Chapter.


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