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Based on interview and document review the hospital failed to protect and promote each patient's rights to be free from all forms of harassment when the hospital utilized aggressive payment collections tactics at the point of patient care for 7 of 21, (Patient #13, 14, 15, 16, 17, 31 and 32), medical records reviewed. Patients and patient representatives were interviewed and complaint forms were reviewed and revealed patients felt harassed, and shocked by the aggressive collections, in each case while the patient or family member was still hospitalized. Staff interviews revealed that registration staff were trained to ask for copays, coinsurance and past due amounts when patients were still receiving care. Staff were threatened with disciplinary action if they failed to collect their quota. Staff stated they were trained to keep asking for payment after patients stated they were not able to pay, and were to set up payment plans. Due to the pervasive nature of the practice the noncompliance was found to be condition level noncompliance. See A145.

Based on interview and document review the hospital failed to respond promptly with resolution of patient grievances for 4 of 14 patients reviewed ( #13, 15, 16, and 17), who filed grievances regarding the harassment by hospital registration staff to collect current and past debt during the registration process while the patients were receiving care in the emergency department and hospital. Findings include:

Patient #13 was interviewed on 5/7/2012 at 10:10 a.m. and he stated that he had surgery at the hospital in 2011. Prior to his surgery he stated a staff person called him and stated that they were estimating his coinsurance bill after surgery to be about $10,000.00. He stated that they asked him how he would like to pay the bill that night. He stated that he had not yet been admitted to the hospital and was not going to pay a bill when he had not even had surgery yet. Patient #13 stated he was shocked by their collections process and had never before heard of such a thing. Patient #13 stated he made a complaint about the process. Although Patient #13 received a written response to his complaint, the hospital did not follow their grievance procedure to update the patient within 7 days if the investigation would take longer than 7 days.

Medical record review revealed that Patient #15 was admitted to the hospital through the emergency room with leukemia and a fever in 4/2010. A concern form provided by the hospital dated 4/27/2010 revealed that Patient #15's parent contacted the hospital to make a complaint and stated that admissions staff walked back to the care area to pursue payment. She stated in the document that it was pretty poor time to be " badgering patients and family members about copay that might be moot if the patient gets admitted anyway. " The complaint form further indicated that she wondered if collections could not be done in a less aggressive manner. The concern form indicated that Patient #15's parent did not receive written notice of the grievance resolution.

Medical record review revealed that Patient #16 was admitted to the hospital in April 2012 for out patient services. A concern form provided by the hospital and dated 4/19/2012 was reviewed and revealed that Patient #16 contacted the hospital to complain about being approached for payment on a bill from a previous visit while checking in. The concern form indicated that Patient #16 stated that being approached for payment of a bill she had received 2 days prior made her feel like a " criminal. " The concern form was reviewed and indicated that Patient #16 did not receive written notice of the grievance resolution.

Medical record reviewed revealed that Patient #17 was admitted to the hospital in 9/2011 for delivery of a baby. A concern form dated 9/21/2011 provided by the hospital was reviewed and revealed that Patient #17 contacted the hospital about a staff member who approached her the day after delivering her baby to ask her how she intended to pay the hospital bill, which they had calculated. The concern form revealed that they asked for a credit card or check. The concern form indicated that Patient #17 was " blown away " by the encounter and was not even sure it was legitimate. Although Patient #17 did receive written notice of the grievance resolution, the grievance was filed 9/27/11 and the written notice was sent 11/15/11, more than 30 days after the grievance was filed.

Employee A/Manager of Patient Relations was interviewed on 5/4/2012 at 10:15 a.m. and stated that these concerns were not considered grievances because they were considered billing issues and billing issues are not considered grievances.

The policy titled Patient Grievance/Complaint Process dated 3/12 was reviewed and revealed under definition: " By nature, complaints are informal, oral and are resolved promptly by staff present. Complaints are issues that can be resolved by making minor changes in a timelier manner than a written response ...

Grievance: a formal or informal written telephonic or verbal complaint that is made to the facility by a patient or the patient ' s representative regarding: ...billing complaints related to rights and limitations as provided by 42 CFR 489. "

V. Grievance/Complaint Investigation and Response for Fairview Hospital-based Services: If resolution of a complaint will extend beyond 7 days, the hospital should inform the patient/patient representative and give them a time frame of when they will receive a written response. The investigation and resolution process should not exceed 30 days for a concern or grievance/complaint, unless the patient and/or their representative and the site grievance/complaint contact agree upon a different time frame. The resolution of the grievance/complaint should be provided in writing to the patient as soon as reasonably possible, but in any event, no later that 30 days after resolution of the grievance/complaint.

Based on interview and document review the hospital failed to ensure each patients right to be free from all forms of harassment for 7 of 21 patients reviewed, Patients #13, 14, 15, 16, 17, 31 and 32 who experienced harassing behavior by registration staff related to bill collections. Findings include:

Patient #32 ' s medical record indicated that she arrived by ambulance, from an urgent care, on 03/18/12 at 11:00 a.m. She had symptoms of chest discomfort, chills, sweats, and an elevated temperature of 101 degrees. Patient #32 was treated in the emergency room and later discharged to home on 3/18/2012.

Patient #32 was interviewed on 05/25/12 at 1:05 p.m. She stated she was taken by ambulance from an urgent care to the ED on 03/18/12. She had symptoms of chest pain and difficulty breathing. She thought she was having a heart attack. She had never had an emergency room encounter in her lifetime and when they transported her from the urgent care to the ED in an ambulance, she was anxious and " scared out of my mind. " After the lab drew blood work, a woman dressed in business attire came in to the patient ' s exam room. The woman identified herself as an administrative employee. The woman had a rolling cart with a computer on it. The woman asked her some general questions like her name and address, and then told her that she owed the hospital $672.00 for services she had received so far that day. The patient told the woman she didn ' t have her wallet with her. The patient asked the woman to leave the exam room and the woman complied. The patient stated she was " angry, scared, and appalled " that a hospital employee would ask her for money when she thought she was having a heart attack. The patient felt this was " unethical. " Shortly after the woman left the exam room, the patient was taken for a chest x-ray. The physician then updated the patient that she had classic pneumonia and intravenous antibiotics were administered. The physician advised the patient that she should be hospitalized overnight, but the patient opted to discharge because she had already been informed that she owed the hospital $672.00 and she wasn't sure she had the financial resources to pay the bill.

Patient #31's medical record indicated that she presented to the ED on 03/13/12 at 12:03 p.m. She arrived ambulatory with complaints of painful nodules on her lower extremities and left upper extremity. Patient #31 was treated in the emergency room and was later discharged to home on 3/13/2012.

Patient #31 was interviewed on 05/25/12 at 10:45 a.m. She stated she called her primary provider because she observed that her legs were swollen with painful nodules. Her primary provider advised her to go to the ED. When she arrived at the ED her blood pressure was elevated. She does not normally suffer from hypertension. Staff kept taking her blood pressure because it was " dangerously high. " She had blood work drawn and a chest x-ray. Shortly thereafter, a gentleman came in to her exam room and identified himself as being from the " Fairview Admissions Department. " He informed her that she needed to pay a bill for previous services she had received from Fairview. The bill was $100.00. She thought it was odd. She had never been asked for money before, when being a patient in the ED. When she questioned him, he said it was Fairview's new policy. She was " in a fog " due to concern over her elevated blood pressure since she had no history of hypertension. The gentleman from admissions was an " irritant " and she paid the bill with a credit card, just to get rid of him. She was later discharged from the ED and was seen by her primary provider the next day. Her primary provider ordered a cardiac MRI, which was conducted at Fairview about two weeks later. She checked in with the Radiology Department for the procedure. She completed some paperwork and they applied an ID bracelet to her wrist. She was then directed to a separate room to speak with the admissions/billing department, who told her that she needed to " pay up " her bill. She told the clerk she didn't have an outstanding bill with Fairview. The clerk told her it was for a bill she hadn't received yet and it was Fairview's new policy to collect the money up front. The clerk's approach wasn't very friendly. She told the clerk she wasn't paying for services she hadn't received yet. The clerk told her if she didn't pay the money, it would make him look bad. She told the clerk to make a computer entry, noting that she declined to pay. The clerk refused and continued to "pressure" her for the money. The clerk was pre-billing her for the MRI services plus attempting to double-bill her for services she had received two weeks prior in the ED (which had already been paid).

Medical record review revealed that Patient #15 was a 7 year old patient admitted to the hospital through the emergency room with leukemia and a fever on 4/20/2010. A concern form provided by the hospital dated 4/27/2010 revealed that Patient #15's parent contacted the hospital to make a complaint and stated that admissions staff walked back to the care area to pursue payment. She stated in the document that it was pretty poor time to be "badgering patients and family members about copay that might be moot if the patient gets admitted anyway." The complaint form indicated that staff initially asked if the patient's mother had a credit card, and she mentioned she does not use credit cards, staff then asked if she had her checkbook. The complaint form further indicated that she wondered if collections could not be done in a less aggressive manner.

Medical record review revealed that Patient #14 was a 6 year old patient transferred to the hospital by ambulance for a femur fracture he experienced after falling from playground equipment on 4/24/2012. Patient #14 was admitted to the hospital for orthopedic surgery and was later discharged to home on 4/26/2012.

Patient #14's father was interviewed on 5/7/2012 at 9:50 a.m. and stated that his son was initially seen in another hospital and then transferred to the emergency room by ambulance and he followed in his car. He stated that when he entered the emergency room a staff member handed him a bill for services rendered thus far and asked how he would like to pay for it. He stated that he felt harassed by the staff member. Patient #14's father further stated that when his wife left to go to use the restroom a staff member approached her for payment as well. He stated his wife finally paid the copay just so staff " would leave us alone." He stated he had never been to a hospital that asked for money for an ER visit and it increased his stress on a difficult day. Patient #14's father filed a complaint with the hospital and stated that he was "infuriated" by the staff treatment.

Medical record review revealed that Patient #16 was admitted to the hospital on 4/18/2012 for nuclear medicine services for abdominal pain. A concern form provided by the hospital and dated 4/19/2012 was reviewed and revealed that Patient #16 contacted the hospital to complain about being approached for payment on a bill from a previous visit while checking in. The concern form indicated that Patient #16 stated that being approached for payment of a bill she had received 2 days prior made her feel like a "criminal."

Patient #16 was interviewed on 5/8/12 and stated that she after she was registered, a staff member called her up and asked for payment. She stated that she thought this procedure should be covered. Then the staff person stated that she owed money on her account from a previous visit. Patient #16 stated that staff kept pushing for payment that day for a bill that was unrelated to what she was there for. Patient #16 stated she felt harassed, embarrassed and stressed by the process, because the amount due was not delinquent and the staff member kept pushing for payment in a public area. Patient #16 stated she complained about the process and later, while she was in the scanner, a supervisor came in to discuss the concern. Patient #16 was told that this process was the new policy at the hospital.

Patient #13's medical record indicated that he was admitted for same day surgery for discectomy decompression, left L4-L5 on 8/10/2011. Patient #13 was later discharged to home on 8/10/2011.

Patient #13 was interviewed on 5/7/2012 at 10:10 a.m. and he stated that he had surgery at the hospital in 2011. Prior to his surgery he stated a staff person called him and stated that they were estimating his coinsurance bill after surgery to be about $10,000.00. He stated that they asked him how he would like to pay the bill that night. He stated that he had not yet been admitted to the hospital and was not going to pay a bill when he had not even had surgery yet. Patient #13 stated he was shocked by their collections process and had never before heard of such a thing. Patient #13 stated he made a complaint about the process. Patient #13 stated he was told that they were estimating his bill to protect him from the "shock" of a big bill after surgery. Patient #13 stated that had subsequently had surgery and owed nothing in coinsurance.

Medical record reviewed revealed that Patient #17 was admitted to the hospital in 9/20/2011 for delivery of a baby by Cesarean section. Patient #17 was discharged to home on 9/25/2011. A concern form dated 9/21/2011 provided by the hospital was reviewed and revealed that Patient #17 contacted the hospital about a staff member who approached her the day after delivering her baby to ask her how she intended to pay the hospital bill, which they had calculated. The concern form revealed that they asked for a credit card or check. The concern form indicated that Patient #17 was " blown away " by the encounter and was not even sure it was legitimate.

Employee (H)/Director of Patient Access & Finance was interviewed on 05/02/12 at 12:55 p.m. She stated that approximately two years ago, management contracted with a company(Accretive) to increase the hospital's revenue at the patient's point of service (Registration staff were employed by the hospital but required to take direction from a hospital contractor (Accretive) in the manner in which they accomplished their work). Debt collection from patients was accomplished in three ways: collecting the patient's insurance co-payment at the time service was rendered, collecting the patient's co-insurance at the time service was rendered (the portion of the patient's charges that were estimated to be uncovered by the patient's insurance carrier), and collecting outstanding balances the patient had from former hospital services, at the time new service was being rendered. The contractor, Accretive, had designed computerized tools which provided financial information to the hospital employees, registration staff, who registered patients for hospital services in the emergency departments, radiology, and surgery. The hospital's registration staff were trained by Accretive to utilize the tools to collect money from patients and check the patient's prior balance, at the point of service. Accretive trained the hospital's employees by " scripting " their conversation with patients, to increase a better outcome with debt collection and cash flow. The training was assertive scripting and hospital employees were coached and shadowed by Accretive employees to increase success when patients owed the hospital money.

Ten of ten registration staff, interviewed between 05/02 - 05/05/07/12, all confirmed that they had been trained by Accretive employees to collect payments from patients, through " scripting " designed by Accretive, that did not allow the patient to opt out of immediate payment (Registration staff were employed by the hospital but required to take direction from a hospital contractor (Accretive) in the manner in which they accomplished their work). Not only were employees required to ask patients for co-payments, co-insurances, and outstanding balances, but employees were also required to aggressively pursue setting up a payment plan for the patient, if the patient was unable to pay the full amount at the point of service. Employees were required to tell the patient that the hospital accepted cash, checks, and a variety of credit cards. All of the employees stated they were uncomfortable with the " scripting, " but were required by their superiors to implement it. The employees were given weekly quotas regarding how much money they were each required to collect from patients. The top collectors were stroked publicly and those who weren't at the top were told they could lose their jobs if collections were not on point.

Employee (U) stated she didn't like the way she was required to pressure patients. Accretive employees accompanied her at the patients' bedside to monitor her process and then provide feedback to her about how she could adapt her approach with patients to assertively increase money collection.

Employee (P) stated that patients were " strong-armed. " She was made to feel like she had to " beat patients over the head to collect. "

Employee (M) stated that patients and parents of patients got upset when attempts at money collection were undertaken. The " scripts " were harsh at a time when most patients were vulnerable.

Employee (S) stated the " scripting " was intimidating to patients and very pushy. " Accretive's goal was to never give up collecting money from a patient ...keep pushing and pressuring. "

Employee (Q) stated staff became " bill collectors ...a lot of patients got upset about me asking for the money ...I thought it was unethical ...one patient accused me of being the mafia ...another patient was appalled and informed (employee Q), " I probably won ' t even be here in six weeks " (the patient had a terminal diagnosis).

Ten of ten registration staff all stated they had recently received e-mail notifications from their superiors that they were to stop using the tools designed by Accretive, effective 04/30/12. The employees stated they had been instructed to collect only the patient ' s co-payment, after 04/30/12, which was the observed practice during the investigation on 05/02, 05/03, and 05/04/12. The employees also stated they were wary that the hospital would simply develop another method for them to collect monies for the patients' co-insurance and outstanding balances. Employee (H)/Director of Patient Access & Finance confirmed that the hospital was exploring other tools for debt collection.
A document titled Fairview Health Services;Prior Balance Collection Scripts dated 9/2/2012 utilized by radiology and provided by the hospital, was reviewed.

Under Scenario #1 "Patient has unsettled balances" Staff were to say "M_______, When reviewing your account, I noticed you have $__.__ in charges due from past visits to this hospital. We accept cash, e-check or credit card to take care of these balances today. (STOP! DO NOT SAY ANYTHING MORE UNTIL PATIENT RESPONDS)" If the patient were to state "I can't pay that much now." Staff were to ask, "May I ask the reason that you are unable to settle your prior balances today?" If the patient responded "I am not in a financial position to pay this today." Staff were to respond, "I understand M______. It is very important that you put a plan in place today to make progress toward settling you open balances. What CAN you pay today? (STOP! DO NOT SAY ANYTHING MORE UNTIL THE PATIENT OFFERS PAYMENT AMOUNT.)"

Under Scenario #3; "PATIENT IS NOT WILLING TO MAKE PAYMENT OR SET UP PATIENT FINANCING." Staff were to say, "Given the fact that you are not willing to make ongoing arrangements to settle prior balances, the next course of action is normally to send the unresolved accounts to a collections agency. If you change your mind or your financial situation changes, please call the hospital customer service to make arrangements to settle your accounts."