When is it OK to have financial discussions with patients?
A reasonable attempt should be made to have the discussion as early as possible, before a financial obligation is incurred (i.e., before care is provided). Timely discussions help ensure that patients understand their financial obligation and that providers are aware of the patient’s ability to pay and/or the source of payment.
- In the ED setting, no patient financial discussions should occur before a patient is screened and stabilized, in accordance with the Emergency Medical Treatment and Active Labor Act (EMTALA) and other federal, state, and local regulations governing the ED.
- If the medical screening determines that a patient has an emergency medical condition, the financial discussion should occur during the discharge process. For patients who do not have an emergency medical condition, following the medical screening, discussion may occur during either the registration or discharge process.
- Outside the ED setting, discussions may take place during the registration or discharge process in a location that does not disrupt patient flow.
Across all care settings, if a patient consents to a financial discussion during a medical encounter to expedite discharge, the best practices support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow.
Who should participate in financial discussions with patients?
For routine scenarios, such as patients with insurance coverage or a known ability to pay, financial discussions should take place between the patient or guarantor (i.e., the person responsible for payment of the bill) and properly trained provider representatives.
For nonroutine or complex scenarios, such as uninsured or underinsured patients, a financial counselor or supervisor should be involved, according to the best practices.
Health coverage is complicated and not all patients are well equipped to navigate this terrain. Patients should be given the opportunity to request a patient advocate, family member, or other designee to help them in these discussions.
Do patients have the right to receive care, regardless of their ability to pay?
Yes—in the case of an emergency. For nonelective services (as defined by the provider), patients should be informed that their ability to resolve any prior balances, or their share of the services they are currently receiving, will not affect provision of care. In other words, ED patients should be informed that their ability to pay will not interfere with treatment of any emergency medical conditions.
Uninsured ED patients should also be informed that the goal of collecting information is to identify paying solutions or financial assistance options that may assist them with their obligations for the ED visit.
“Now that the Affordable Care Act’s insurance marketplaces are fully operational and Medicaid has expanded eligibility criteria in some states, it is more important than ever for hospitals to help patients understand their coverage options. Inevitably, some patients will learn about these new coverage options for the first time when they are in need of emergency care.”
—Richard L. Gundling, FHFMA, CMA, HFMA Vice President, Healthcare Financial Practices
Prior to receiving elective services (as defined by the provider), patients are obligated to make satisfactory financial arrangements. Those who have prior balances should be informed if the provider’s policies regarding prior balances mean the service will be deferred. It is important to note that this doesn’t mean patients should be required to pay a prior balance in full before receiving an elective service. Instead, the best practices call for the patient to make mutually acceptable payment arrangements to resolve the outstanding balance, in accordance with whatever policies a hospital may have in place.
Across all care settings, it is important to have clear and publicly available policies on how to interact with patients with prior balances. Also, providers should have clear definitions of elective and nonelective procedures. These definitions also should be made available to the public.
What topics are typically covered during a routine patient financial discussion?
Once a patient is stabilized, basic registration information, including demographics and insurance coverage, is gathered, and the potential need for financial assistance may be determined. The provider representative should review insurance eligibility information with the patient to ensure the information is accurate.
If appropriate, the patient may be referred to a financial counselor and/or offered information regarding the provider’s financial counseling services and assistance policies. Providers should have a widely publicized toll-free number for patients to call to receive assistance in financial matters and address any concerns they may have.
For communications in advance of service, the provider should maintain a thread of preregistration discussions and avoid repeated requests for the same information.
What can providers do to make financial interactions easier for patients?
The provider should take the initiative to communicate with the patient about financial matters. When the provider raises the subject, it actually takes a burden off the patient. Communication should include verification of patient information (mailing address, phone numbers, email address, etc.) and the patient’s preferred methods for future communication.
Communication should be understandable by the patient and should use standard language. Clinicians have long used standard language in patient discussions, such as when taking a patient’s medical history, for example. Likewise, provider organizations should have standard language to guide finance staff on the most common types of patient financial communications. In developing that language, providers should take the patient’s perspective into consideration.
Patient privacy should be respected in all patient financial discussions. Conversations should occur in a location and manner that are sensitive to the patient’s needs.
Discussions should be reinforced with written information. During the registration or discharge process, the patient should receive written information about the provider’s supportive financial assistance programs and other materials as required by 501(r) regulations for not-for-profit organizations, and a summary of the potential financial implications for the services rendered, including a phone number to call with questions. Equally important, financially supportive policies should be communicated and made available to the community.