Self-Pay Collections – Are you leaving money on the table?

Christopher Smet

In today’s healthcare market we are seeing significant shifts in payment models, in particular towards increased patient responsibility for services by way of consumer directed or high deductible health plans.  For many of you reading this, 30 percent or more of your revenue stream is coming directly from the patient accounting for copays, deductibles, co-insurance, and self-pay for services.1  As more employers move toward the adoption of high deductible health plans, the trend we are seeing will likely only increase.  So with change comes new challenges and complexities, and with the marked increase with consumer-directed health plans, healthcare delivery systems need to leverage technology and policy in ways they may not have needed to in the past.

So, what steps should we all be taking right now?

The starting point begins with assessing your current resources and capabilities.  For example, what are your front-end teams responsible for today?  Where in your workflows are you giving your teams the opportunity to request payment from the patient (it should be prolific!).  Do you have a set of policies in place for minimum amount due at time of service and, perhaps more to the point, how do you define success through metrics?

From a technology standpoint, for many organizations, there is a need to tighten the relationship between your EDI 270/271 transaction set with your point of service collections, by integrating the eligibility content received with your front end workflows in a manner that supports your staff.  At the end of the day, we really do not want front end users having to interpret a 271 response or navigate the various benefits; however, we want the advantage of having access to current liability amounts via an electronic workflow.  What we want and need is a simplified process that provides the user with clear and intuitive patient responsibility amounts supported by an enterprise-wide script/policy/procedure that allows them to have a well-defined conversation with the patient resulting in a payment.

So, the areas to consider include process reviews.  Do you have a standard workflow across your organization?  Is change management supported by technology, i.e., do you have workflows that are enforced via your technology suite that takes the user through the same process every time, regardless of their location?  If your answer to this question is no, you have a starting point on where to begin your evaluation and workout with your teams.

What are some measures to consider?

A metric is only as good as what you can actually do with it.  It should be well-defined and serve as something that connects people, process, and technology to the best extent possible.  Some Key Performance Indicators to consider include:

•    Copay Accuracy – All Copays

•    Copay Accuracy Incorrect Copays

•    Dollars Transferred to Collections

•    Average Self Pay Write Off Amount

•    Self-Pay A/R Days

•    Self-Pay Cash at POS

•    Percent Default On Budget Plan

•    Budget Plan Accounts

•    Budget Plan Accounts In Default

With any metric, the value and benefit to the organization is what you do with it.  With the KPIs stated above, the critical need is linked to how the information is published and shared across the organization – to have a process and policy in place is a great thing, to support this with a well-rounded communication plan with clear goals in place is an altogether different organizational experience.  So what are the baseline and stretch goals for your locations and departments?

Am I partnering with my vendor(s)?

As mentioned above, good results are an outcome from a combination of good people, good process, and the right level of technology.  One observation, coming from the vendor’s perspective, is the fact that we have high value solutions that many are still not leveraging today.  Why is this?  For many of you, there are bandwidth issues with programs and projects linked to Meaningful Use and ICD-10.  For others, there may be a need to improve the line of site into the true ROI of the solution.  For any customer that has been operating on a practice management system for more than five years, there is an acute need to partner with your vendor to better understand what high value solutions are available to help you improve your cost to collect via automation and process simplification.

I am sure many familiar concepts have been highlighted and to that end, I would encourage you to look to your peers, your vendors and partners, as well as your KPIs, to assess where you may be in the most need of assistance.

In closing, perfection is elusive.  Keep the focus on what can be measured and influenced in real and meaningful ways.

Best regards,




1 Source: 2007 & 2013: “The ‘Retailish’ Future of Patient Collections,” Celent, February 2009; 2011: MGMA Practice Perspectives on Payment – 2009, median data reported


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