HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow their adopted policy related to Patient Rights and the implementation of good management techniques, by failing to follow their adopted policy related to the collection of financial information and collection of co-pays, by failing to refrain from requesting co-pays from the patient until the medical screening examination and necessary stabilizing treatment have occurred, in the Emergency Department for one of one medical records reviewed (MR1), and failed to ensure that applicable job descriptions were consistent with facility policy.

Findings include:

Conemaugh Memorial Medical Center ... PolicyStat ID: 1970090 ... Policy Area: Organizational-Clinical ... Patient Rights policy and procedure dated December 2015. "Statement of Policy: It is the policy of Conemaugh Health System (CHS) to respect the rights of patients during their hospitalization and to recognize that each patient is an individual with unique health care needs. Staff will provide considerate, respectful care, incorporating personal values and belief systems and strive to protect each patient's dignity. ... A Statement of the Patient's Rights ... 9. You have the right to high quality care and professional standards that are always kept and reviewed. ... 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid personal discomfort. ... 25. You have the right to voice questions, concerns, or comments to your health care provider, to the Patient Representative at the hospital or you may contact the Pennsylvania Department of Health, Acute and Ambulatory Care Services, ... ." Attachment entitled, "A Statement of the Patient's Rights" revealed, "... 1. You have the right to respectful care given by skilled staff. ... 8. In case of emergency, you can expect emergency treatment without delay. ... 9. You have the right to quality care and high professional standards that are always kept and reviewed. ... 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid any personal discomfort. ... ."

"LifePoint Health ... Collection of Financial Information in the Emergency Department", Review Date 3/31/2016, which stated, "Scope: All facilities affiliated with the Company including, but not limited to, hospitals, ambulatory surgery centers, home health agencies, physician practices, and all corporate departments and divisions. Purpose: To ensure registration personnel collect financial information in the Emergency Department in accordance with governmental regulations ... Procedure: Each patient seeking treatment in the Emergency Department is entitled to an emergency medical screening examination. When collecting financial information in the Emergency Department setting, the following minimum guidelines must be adhered to: ... 2. A medical screening examination ... for an Emergency Department patient may not be delayed in order to: Inquire about an individual's ability to pay; Inform the patient that he or she must pay for his/her care if they choose to be treated; Perform insurance verification and authorization; or Inform the patient that his/her care will be free or at a lower cost if they transfer to another facility ... 4. The registrar must refrain from making any remarks which the patient might interpret to mean services may not be provided based on his/her ability to pay ... 5. The registrar must refrain from requesting co-pays, deductibles, or past due balances from the patient until the medical screening examination and necessary stabilization have occurred. 6. If a patient expresses the intent to leave the Emergency Department, the patient should be encouraged to remain in the Emergency Department until receiving a medical screening examination and necessary stabilization. If a patient leaves the facility as a result of questions asked prior to receiving a medical screening examination and necessary stabilization, it may be interpreted that there was a suggestion to the patient to leave ... Process: Registration procedures should be developed to ensure the guidelines outlined above are included in day to day processes and basic identifying information is obtained in order to utilize the order entry systems and expedite patient care. 1. If a patient presents to the Emergency Department with an obvious life-threatening emergent condition ... the medical screening examination and necessary stabilization will begin immediately. The registrar may obtain the information identified in step 4 below from a source other than the patient (e.g., next of kin). Otherwise, this financial information should be obtained after the patient has received a medical screening examination and necessary stabilization treatment. The patient may be informed of his/her potential financial liability after necessary stabilization. 2. In the case of an emergent situation or active labor, identified after the medical screening examination, stabilization treatment will begin immediately. The registrar may obtain the information identified in step 4 below as well as insurance verification and authorization, so long as necessary stabilization treatment is not delayed. The patient may be informed of his/her potential financial liability after necessary stabilization ... 3. If the medical screening examination determines that the patient does not have an emergency medical condition, or the patient is not in active labor, the patient should be informed of the risks and benefits of his/her treatment options. The registrar may obtain the information identified in step 4 below, as well as insurance verification and authorization. After the the medical screening examination is completed and once the qualified medical provider has made the determination that an emergency medical condition does not exist, the patient may be informed of his/her potential financial liability ... 4. A registration process may be initiated as long as the process does not cause delay in the provision of a medical screening examination and necessary stabilization for an identified emergency medical condition. Basic identifying information may be gathered and entered into the computer to allow for processing of tests in the order entry or applicable systems. Basic information obtained may include: Patient's full name; Patient's date of birth; Social security number; Family physician; and insurance plan information, if applicable ... Implementation ... The Registration supervisor should observe personnel throughout the employee's evaluation period to ensure compliance with this policy. Deviations from this policy will be reported as part of the hospital's performance improvement and the appropriate corrective action taken to ensure compliance ... Definitions ... Medical Screening Examination: The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. It involves an evaluation by a qualified medical provider, within the capability of the hospital's Emergency Department, to determine whether or not an emergency medical condition exists, or if the person is in labor. The medical screening examination is an ongoing process and represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures, depending on the patient's presenting symptoms ... Stabilization: Stabilization includes the provision of such medical treatment for the condition, necessary to assure within reasonable medical probability, that no material deterioration of the condition is likely to result from, or occur during, the transfer of the individual from a facility, or that the woman has delivered the child and the placenta. Stabilization may include either stabilization for transfer or stabilization for discharge ... It is the responsibility of the Chief Financial Officer to ensure adherence to this procedure ... ."


"LifePoint Health ... Collection of Financial Information in the Emergency Department", Effective 8/31/2018, which stated, "... Scope: This policy applies to all subsidiaries and affiliates of LifePoint Health, Inc. (the "Company") and all employees of any of them. Purpose: To ensure registration personnel, including contractors, collect financial information in the Emergency Department in accordance with this policy and associated governmental regulations. Definitions: Medical Screening Examination: The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exit. It involves an evaluation by a qualified medical provider, within the capability the hospital's Emergency Department, to determine whether or not an emergency medical condition exits, or if the person is in labor. The medical screening examination is an ongoing process and represents a spectrum ranging from a simple process involving only a brief history and physican examination to a complex process that also involves performing ancillary studies and procedures, depending on the patient's presenting symptoms. Emergency Medical Condition: A condition, including severe pain, psychiatric disturbances and/or symptoms of substance abuse, in which the absence of immediate medical attention could reasonable be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious dysfunction of any bodily organ or part, or with respect to pregnant woman who is having contractions, there is inadequate time to effect a safe transfer to another hospital before delivery or the transfer may pose a threat to the health or safety of the woman or the unborn child, and a condition in which there is potential for further deterioration if not treated in the foreseeable future. Stabilization: Stabilization includes the provision of such medical treatment for the condition, necessary to assure within reasonable medical probability, that no material deterioration of the condition is likely to result from, or occur during the transfer of the individual from a facility, or that the woman has delivered the child and the placenta. Stabilization may include either stabilization for transfer or stabilization for discharge ... Policy: Per the Emergency Medical Treatment And Labor Act (EMTALA) guidelines, there should be no delay in providing a medical screening examination (MSE) or necessary stabilizing treatment to patients by inquiring about an individual's insurance or ability to pay for care ... Hospitals may continue to follow reasonable registration processes for individuals presenting with an emergency medical condition. Reasonable registration processes may include requesting information about insurance as long as these procedures do not delay the MSE or stabilizing treatment ... Procedure: Each patient seeking treatment in the Emergency Department is entitled to an emergency MSE. When collecting financial information in the Emergency Department setting, the following minimum guidelines must be adhered to ... 2. A MSE for an Emergency Department patient may not be delayed in order to: Inquire about an individual's ability to pay. Inform the patient that he or she must pay for his/her care if they choose to be treated. Perform insurance verification and authorization. Inform the patient that his/her care will be free or at a lower cost if they transfer to another facility ... 4. Registration personnel must refrain from making any remarks which the patient may interpret to mean services may not be provided based on his/her ability to pay ... 5. Registration personnel must refrain from requesting co-pays, deductibles, or past due balances from the patient until the MSE and necessary stabilizing treatment have occurred. 6. If a patient expresses the intent to leave the Emergency Department, the patient should be encouraged to remain in the Emergency Department until receiving a MSE and necessary stabilizing treatment. If a patient leaves the facility as a result of questions asked prior to receiving a MSE and necessary stabilizing treatment, it may be interpreted that there was a suggestion to the patient to leave ... Process: Registration procedures should be developed to ensure the guidelines outlined above are included in day to day processes and basic identifying information is obtained in order to utilize the order entry systems and expedite patient care. 1. If a patient presents to the Emergency Department with an obvious life-threatening emergency condition ... the MSE and necessary stabilizing treatment will begin immediately. Registration personnel may obtain the information identified in step 4 below as well as insurance verification and authorization, so long as the necessary stabilizing treatment is not delayed. The patient may be informed of his/her potential financial liability after necessary stabilizing treatment. When it is determined that an emergency medical condition no longer exists, the patient may: Accept treatment and financial liability ... Refuse additional treatment ... 3. If the MSE determines that the patient does not have an emergency medical condition, or the patient is not in active labor, the patient should be informed of the risks and benefits of his/her treatment options ... After the MSE is completed and once the qualified medical provider has mad the determination that an emergency medical condition does not exist, the patient may be informed of his/her potential liability ... Refuse treatment ... 4. A registration process may be initiated as long as the process does not cause a delay in the provision of a MSE and necessary stabilizing treatment for an identified emergency medical condition. Basic identifying information may be gathered and entered into the computer to allow for processing of tests in the order entry or applicable systems. Basic information obtained my include: Patient's full name. Patient's date of birth. Social security number. Family physician. Insurance plan information, if applicable ... Implementation ... 3. The Registration supervisor should observe personnel throughout the employee's evaluation period to ensure compliance with this policy. Deviations from this policy will be reported as part of the hospital's performance improvement and the appropriate corrective action should be taken to ensure compliance. It is the responsibility of the Chief Financial Officer to ensure adherence to this procedure ... ."


Review of Job Description entitled "Registration Specialist", dated June 2015, revealed, "... Job Summary: Responsible for obtaining and verifying all patient demographics and insurance information during the registration process. Registration Specialists will minimize the financial risk of providing services by assessing the patient's financial status, verifying all account information, obtaining signatures on all required hospital and regulatory forms and obtaining applicable patient payments prior to services being provided ... Essential Responsibilities ... Obtains and verifies all insurance, demographic, and financial information during the registration process and enters/updates the information in the registration system; in compliance with EMTALA regulations. Obtains and scans into document imaging system, if applicable, all required signatures, patient picture identification, insurance cards, Physician orders, consents and financial documents. Identify co-pays, deductibles, co-insurance, self-pay payments and past due balances at the point of service through the use of CarePricer or other insurance verification tools. Inform and educate patient on the amounts due. Collect payments for co-pays, deductibles, co-insurance, self-pay payments and past due balances at the point of service. Payments are to be recorded in HP-24 in accordance with the POS cash collection procedures ... ."


Document entitled "POS Cash Workflow for DEM Staff ", which stated, "Patient is "arrived" to the ER with the following information: --patient Full Name --Date of Birth --Name of PCP --Current Phone Number -- Chief Complaint -- Photo ID is scanned if available --Consents are signed -- Patient Rights and Privacy Notice given -- Patient is Triaged by Clinical Staff. Clinical staff decides if patient is sent to the back or sent to the waiting room. If PIT (Provider in Triage) system is currently being used, the patient also sees a Provider out front. If PIT Process is not currently being used, the patient will see the provider in one of the cubicles in Ultra Track or in the main ER bed. The Provide (sic) indicates in the EPIC system they have examined the patient. The registrar then clicks on the "Ready to Reg/Identify" tab to find this indication ... The Registrar waits for the 1st Provider time to be entered before speaking with the patient and verifying all the information including, demographic and insurance. If the insurance requires a copay, this is also mentioned to the patient. Insurance cards are scanned if available. Registrar offers the 20% discount if patient can pay today or within 7 days. Patient is given a postage paid envelope if they choose to mail in the payment. Phone number is provided if patient prefers to call in the payment."


1. Review of MR1 patient timeline revealed the patient was roomed in the Emergency Department at 16:27, had a first provider evaluation at 16:33, and registration was completed which included collection of a co-pay, at 16:44. Continued review of the patient care timeline revealed that the medical screening examination and stabilizing treatment were still in process after registration and collection of the co-pay. It was noted that an admission order was placed at 18:37.


2. An interview with EMP11, on March 26, 2019, at 11:25AM, revealed, relative to the registration process, is that the patient comes in, the nurse sees the patient in Triage, and decides if the patient goes back or to the Waiting area. EMP11 stated that Registration staff wait until the patient goes back to the room and until after the physician sees the patient, and that is noted on the tracking board, they will then see the the patient as part of the registration process, and if there is a co-pay they will ask the patient for the co-pay. EMP11 stated that if the patient wants to wait to see if they are admitted, they will wait, and once admitted financial counselors will review, and if needed they will credit or refund the co-pay.


3. An interview with EMP12, EMP13, and EMP11, on May 17, 2019, at 10:15AM, was completed. EMP12 stated that they have reviewed the LifePoint policy and they felt that if the patient was seen by the provider, it was acceptable to ask for the co-pay. EMP12 stated that sometimes the copays are collected at the bedside.


4. An interview with EMP14, on May 17, 2019, at 10:35AM, revealed, "Once we have the information verified, the copay will pop up. I check for accuracy. Sometimes their card is old. I tell them there is an ER copay, and if they pay today, we give a 20 percent discount. If they paid an ER copay and they are then admitted, we put that money towards the admission deductible. Once the doctor sees them, the tracking board gives us a provider time that they were seen. Most of the time, the ER copay is collected at the bedside,patients like the idea of a 20 percent discount. I have had complaints though, one lady said to me that this isn't the time. I tell them I understand and that we can discuss later. There's times you don't even bring up the copay, like if the patient is intubated or a trauma."

5. An interview with EMP12 on May 17, 2019, was completed. EMP12 stated that if the patient has more than one insurance, the secondary insurance will pick up the copay, and when the patient relative to MR1 got admitted, they discovered the patient had Medicare, and should not have collected a copay.


6. A telephone interview was conducted with EMP17, on May 20, 2019, at 11:40AM. EMP17 stated related to the registration process and copay collection, that they wait until the first provider sees the patient, and then will get address, phone number, insurance, mention the co-pay, and advise patients that if money is collected today, they will get a 20 percent discount. EMP17 stated that if the patient is admitted, most insurances have an admission co-pay as well and any ER copay already collected would be applied to that. EMP17 stated that they are never to say wait on the copay until admitted. EMP17 stated that a lot of people are not happy about this process, and stated that they had received a script to follow. EMP17 stated "... It's turned into a competition, there's a goal every month ... ."

7. Document entitled, "Scripting for DEM copays at Bedside", which stated, "Insurance has been verified: Registrar: Mr/Ms .... I hope you are feeling better now that you have seen the Dr. We have verified your insurance and there is a co-payment of $... Will you be paying with cash, check, credit or debit card? You will receive a 20% discount if you make the payment today. Patient Concerns: Never had to pay before.
Patient: I never had to pay at the time of service before.
Registrar: Mr/Ms ... I understand your concern, but changes in office procedure were needed to contend with rising costs of health care. Paying at the time of service helps us to avoid additional administrative costs, which saves you money. Plus, it lets you take care of your payment now rather than worry about a bill later, plus you get a 20% discount if you pay today. Would you like to pay by cash, check, credit or debit card?
Insurance will pay.
Patient: My insurance will pay.
Registrar: Mr/Ms ... based on the contract we have with your insurance company, you have a co-payment amount that is your responsibility. If you have questions regarding your financial responsibility under your insurance plan, your insurance carrier should be able to assist you. Would you like to pay by cash, check, credit or debit card?
Send a bill.
Patient: Just send me a bill.
Registrar: Mr/Ms .. you copayment is due at the time of service. If you pay today you will get a Discount of 20%. Make sure you mention the 20% discount!
Revised 2/1/16."

8. A telephone interview was conducted with EMP18, on May 20, 2019, at 3:05PM revealed that staff are taught in orientation to verify information, talk about insurance estimate and to provide information relative to copays. EMP18 stated patients are asked to pay or they are given an envelope, and stated that if no one is with the patient, the staff will pull up the medical record and verify insurance and then call patient after or wait until someone comes in. EMP18 stated that if the patient is later admitted, they can apply to the inpatient copay or be refunded, and stated that if the patient has a second insurance, like Medical Assistance, there would not be a copay. EMP18 stated that if they meet the goal at the end of the month, and there is a percentage collected over the assigned goal, there is an incentive process, and stated that they are given a monthly goal, and it is broken down by outpatient department, and that goals are received every month.

9. Document entitled "Run Estimate", which stated "... Do not run estimate when patient has: Medicaid (MA) or Medicaid HMO. Two Insurances. Billing Workers Comp or Auto. Screening Exams ... 1. Click on the Patient View tab ... On the eligibility screen change the service type to Emergency Services ... Click on Estimate at the top of the verification ... 2. Click Connect tab ... Click on the $ to go to estimate. 3. Go to the verifier and click realtime ... change the service type to Hospital Emergency Services ... Now you are ready to run the Estimate ... Service Type enter Emergency Department. You must enter the account number ... Select the insurance company ... Click on eligibility if you need to find the deductible, out of pocket, co-insurance, or co-pay amounts ... Above is the estimate. Select next to have the 20% prompt pay discount apply ... The printed Estimate will show estimated charges, estimated insurance amount, total estimated without 20% discount, the box on the right is the total estimate amount owed with the 20% discount. Remember to Print the Estimate. You now must circle Estimate Worksheet ... You must have the Patient Sign. Scan under Patient Financial Services ... ."

10. A telephone interview with EMP9 on May 20, 2019, at 3:30PM, revealed "Registration staff are not allowed in until the patient has been seen by the first provider. The tracking board updates itself. The doctors will look at it and then take the next patient. Once they assign themselves to a patient, then Registration staff knows they can go in., because the providers would have already been in the room. When advised that copays are being collected as part of the registration process, EMP9 stated, "I didn't know that. That's not how they're supposed to be doing that. I had no idea ... ."