Case Study

Standardizing Patient Estimating to Improve Upfront Collections

About Health First

Health First is located in Brevard County, Florida. The system includes four not-for-profit hospitals with 920 acute-care beds. It also encompasses 15 diagnostic centers, a 300-plus Health First employed physician group and Health First Health Plans.

Health First’s Patient Access division employs more than 200 associates. In most cases, this team’s interactions with each patient bookend the overall care experience with scheduling, pre-authorization, registration, Point of Service (POS) collections at the front end and post-care billing at the back end. Health First found that the content and quality of this team’s interactions with patients were critical to reducing bad debt and increasing POS collections.

Patient Access Touchpoints



Health First’s Journey to Improving Upfront Collections

Hiring and Training Benefits Advisors

It is extremely important to hire the right people. Associates are not just collectors – they are also the face of the organization. They must be comfortable talking with patients and requesting payment with a compassionate, caring approach. That takes a specific skillset that can be hard to find.

In fact, some say that hospitals are finding themselves operating more and more like banks, financing up to 5- to 7-year loans for patients who cannot otherwise afford their health care.

In hiring, we are not just looking for healthcare registration experience. We are looking for candidates who are comfortable talking about money and who provide a high level of customer service. A background in banking can sometimes be the right fit. — Michelle Fox, Director of Revenue Operations Patient Access, Health First

New Mindset for Patient Access

With high-deductible plans, more responsibility is shifting to the patient. Recent studies show that patients experienced an 11 percent increase in average out-of-pocket costs in 2017, with more than 50 percent seeing a per-visit out-of-pocket cost greater than $500.

This requires a new mindset for the revenue cycle. Providers need to take a more upfront, consultative approach when talking with patients who are facing high bills and who often lack a full understanding of their benefits.

But these conversations do not come naturally to most. Staff need training in best practices for patient financial communications – to consult with patients about their benefits and to have clear, focused conversations about financial matters.

Recorded Interactions

  • Authorizations, certifications, referrals
  • Physician calls
  • Verbal orders from on-call physicians
  • Scheduling calls
  • Pricing hotline/estimates
  • Patient calls on nurse helpline
  • Calls in Emergency Department
  • Customer service calls
  • In-person encounters

Quality Monitoring

Health First uses the Trace quality scoring module for a consistent, objective approach to scoring patient interactions.

Scorecards and reports: Track and trend quality scores by team, agent or focus area
Random recording selector: Generate list of randomly-selected recordings to eliminate reviewer bias in scoring
Bookmarking: Bookmark recordings and return to a particular portion during playback
Review with staff: Share recordings and reports for training and performance improvement

Voice Recording

To improve patient financial communications, Health First implemented Trace by Vyne Medical to capture and integrate voice, fax and electronic exchanges that occur across the revenue cycle. Records are digitized and tied to the patient account for search, retrieval and sharing.

Health First uses Trace to record inbound and outbound phone calls with payers, physicians and patients. Associates record calls through a USB connection to their PCs and index recordings to criteria such as patient, physician, insurer and date of service. Hospitals also use the technology platform to capture and digitize faxes from physicians and payers, as well electronic exchanges from payer web sites and ancillary systems.

Once indexed, recordings and documents are searchable and retrievable for playback and viewing through a web-based portal. Links are also referenced in the EHR and placed alongside the care record to form a more a complete view of available patient data.

Recording Patient Financial Conversations

“Anytime we are asking for money, we definitely want to record the conversation, and we reference the recordings on a daily basis,” said  Michelle Fox, Director of Patient Access.

Health First uses the Trace quality scoring module to perform analysis of recorded conversations. They also plan to implement an audio search tool that will allow them to search recordings for key words and phrases.

“By listening, we can see if associates are using key phrases they are trained to use such as, ‘How would you like to pay today?’ versus, ‘Would you like to pay today?’ as well as calling patients by their name and using a caring, empathetic tone,” added Fox. “Those small adjustments make a big difference, and recording is the only way to see if they are being enforced.”

If the department receives a patient complaint, supervisors can listen to the recorded conversations to perform root cause analysis. In some cases, the patient is right and may have been treated rudely. If supervisors find that the employee did not handle a situation appropriately, it is addressed with the employee and a transcript of the recording is attached to the formal write up.

In many cases, however, supervisors find that employees are doing what they are trained to do. For example, a patient received a bill after service and called to complain, saying they were told they would not owe any more than the estimate provided.

The manager responded by telling the patient that since they record all their calls, she would do some research and get back to the patient in about 30 minutes. She listened to the recording and found the associate handled the conversation appropriately, saying, “This is your current estimate, but if your doctor performs another test, please feel free to call back and we can discuss financial assistance if needed.”

The manager returned the call and quickly diffused the situation by telling the patient the recording had confirmed the self-pay amount was communicated accurately as an estimate.

Patient Estimating

Communicating estimates can be a challenge for health systems, as final bills often vary from the estimates provided. While patients want to be informed upfront about costs, they may also be dissatisfied when final bills are higher than expected.

Benefits advisors must know what to ask patients to pay. To address this, Health First shifted to an approach of “100 percent estimate, 100 percent ask.” Patient Access now runs an estimate for every single patient systemwide, even in the Emergency Department (ED).

“Every year, there are changes to patients’ insurance benefits, and payers constantly change their processes,” said Fox. “We can’t assume that we know a payer’s policies and requirements just based on what they were the last time we checked.”

Previously, Health First did not run estimates for Medicare or secondary insurance. Now, the approach is to run the estimate for every patient, every time, regardless of insurance.

We have the mindset that everyone has benefits, whether they are self-pay or insured. We have also found that being able to tell a patient that, ‘We have run your benefits and your plan pays at 100 percent,’ is good customer service.  Patients like to hear when they do not owe anything. This also sets the expectation that a patient will receive an estimate for every visit, whether they owe or are completely covered. — Michelle Fox, Director of Revenue Operations Patient Access, Health First


Patient Estimating in the Emergency Department

When a patient comes to the ED, associates do not always know what level to charge because not all charges have been entered in the system. Staff must choose a default level to charge the patient.

In the ED, there are five levels of charges:


Level 1:

Level 2:

Level 3:

Level 4:

Level 5:

Minor InjuryRequires MedicationRequires X-Ray/TestRequires CT (Chest)Highest Level


Previously, the system’s default was level 3. If charges went beyond this, they had to send the patient a bill for the remainder. After careful analysis and consideration, it was decided to change the default level to 4, based on the historical volumes of ED-level charges.

“If charges are less, we would rather give the patient a refund than have to send another bill,” stated Fox.

Tracking Progress – Reports

Health First uses a technology platform for all front-end verification, eligibility, estimating and propensity to pay. This system is tied to Health First’s contract management and chargemaster system. Within the system, associates add a note with a reference to the Trace recording or image that contains the patient’s authorization information.

“We created a report to track the completion of each piece and monitor this daily,” said Fox. “If we have 50 registrations, we should also have 50 estimates. If not, that is a missed opportunity.”

Outcomes in Upfront Collections

Since shifting to the approach of “100 percent estimate, 100 percent ask,” Health First has reached over $2 million in upfront collections. Within the first month, the system collected its highest percentage of net revenue ever in upfront collections and has experienced an overall increase of 27 percent in upfront collections.

Health First is now routinely reaching 2.7 percent of net revenue in point of service collections, well above the industry average of .7 percent and even the best practice of 2 percent.


Through this process, Health First has been able to capture and integrate patient financial data such as benefits, financial clearance and pre-registration information for enterprise access and exchange. The organization leverages data to assist patients in making informed care decisions, ensuring coverage for services and communicating upfront the cost of services and the role the patient’s insurance will play.

Michelle Fox, DBA, MHA, CHAM
Director of Revenue Operations Patient Access
Health First

Michelle Fox is the director of Revenue Operations/Patient Access at Health First Inc. in Brevard County, Florida. She is responsible for directing revenue operations of the Patient Access Department supporting four not-for-profit hospitals, 15 diagnostic centers and a 300-plus employed physician group. She manages day-to-day operations of more than 200 associates and has earned a Gallup Survey World Class Leader designation.

Michelle is nationally certified in Healthcare Access Management. She holds a Bachelor of Health Science Education, a Master of Health Administration and a Master of Business Administration from the University of Florida, Gainesville.  Michelle recently graduated with her doctorate in Business Administration with a dissertation focus on Pricing Transparency in health care.  She is an active member in HFMA and NAHAM and serves on the NAHAM Board as Vice President.