One man’s debt collector is another man’s revenue cycle manager. At least that’s the big takeaway from Accretive Health’s response to Minnesota Attorney General’s Lori Swanson’s scathing report about Accretive’s business practices within the Fairview Health Services organization of that state.

Accretive wrote a 29-page response to questions from Sen. Al Franken (D-Minn.), who has been investigating the claims against the company made by the attorney general. As part of his investigation, Sen. Franken announced that the Senate Health Committee will hold a hearing in Minnesota later this month.

In its response, Accretive offered a viewpoint dramatically different from the attorney general’s report. While the attorney general portrayed Accretive as a debt collector chasing medical patients by pretending to be a hospital employee, Accretive said its policies, procedures, and software tools were designed to do exactly the opposite: to help patients identify all possible sources, from health insurance, COBRA, automobile insurance, disability, parental/student insurance, military insurance, worker’s compensation, Medicare/Medicaid, charity programs, and more, while at the same time making the patient aware of their fiduciary responsibility up front.

“This means, among other things, making sure insurance claim forms and payor reimbursements are accurate … finding appropriate solutions for the uninsured … [and] educating patients about their financial obligations for their healthcare costs and helping to ensure that they fulfill them,” Accretive wrote Sen. Franken.

Accretive’s Revenue Cycle Management and Quality and Total Cost of Care programs “are fundamentally designed to improve outcomes, primarily by eliminating errors, for healthcare providers and patients,” the company wrote. While it admitted to certain charges made by the attorney general, such as meeting with patients at bedside about medical bills, it did so following strict guidelines and following best practices as established by organizations such as the Hospital Financial Management Association (HFMA).

What follows are Sen. Franken’s questions, and summaries of Accretive’s responses. The complete 29-page response can be found here: 2012-05-11 Franken Response.

Did Accretive employees request payment or attempt to collect past debts from Fairview patients before they received medical treatment?

“Informing patients of prior balances at the time of registration is consistent with the ‘recommended practices’ advocated by the Healthcare Financial Management Association (‘HFMA’),” Accretive responded. However, the policy was not to withhold services until prior balances had been paid. The policy, which appears in Accretive documents in capital letters in bright red, reads:


Is Accretive aware of any information suggesting that these practices led to longer wait times for patients?

Accretive responded that it did not track wait times. The registration processes “typically take no more than a few minutes, and similar processes are followed by virtually every hospital and clinic in this country upon registration,” Accretive wrote. “While it is theoretically possible that filling out routine forms and making any payment arrangements could have led to a slight delay (assuming that treatment was immediately available for non-emergency care within the first minutes of arrival), the benefits provided patients from the registration process – including assistance in understanding insurance benefits or help with having insurance companies resolve prior balances – in our experience generally outweighed any such slight delay.”

Is Accretive aware of any information suggesting that these practices led to any patients refusing treatment or leaving a hospital before receiving treatment?

Again, Accretive did not track whether a potential patient stayed or left, but at least as far as examples in the attorney general’s report are concerned, the patients “did, in fact, receive treatment.”

The report states that Accretive employees were directed to “put together a ‘pre-balance stop list’ the night before
patient appointments so that the patient can be stopped for payment before treatment is rendered.” Is this true?

“This statement is misleading,” responded Accretive. “The purpose of stop lists was not to ‘stop’ treatment. Rather, stop lists identified patients scheduled for certain procedures … with whom Revenue Cycle employees needed to meet to resolve prior balances.” In 98 percent of the cases, the prior balance “was resolved by public or private insurance.” Less that two percent resulted in payment from the patient, Accretive wrote.

The report states that Accretive instructed Fairview employees to predict the “likely” diagnosis and treatment in order to bill patients prior to treatment … If so, how did Accretive instruct its employees or others to make these predictions? How did Accretive identify erroneous predictions? How does Accretive ensure timely refunds to patients who overpaid?

“It is not accurate to say that ‘likely’ diagnosis and treatment were ‘predicted’ ‘in order to bill patients,’” wrote Accretive. “Rather, estimates about a patient’s cost of care were based upon diagnostic codes included in referrals or other documents that hospitals routinely use to schedule appointments. Through the use of Accretive Health’s software tools and diagnostic codes, including the American Medical Association’s CPT (Current Procedural Terminology) Codes, reasonable estimates of the cost of care were prepared in advance, in order to pursue insurance options and other reimbursement. At the same time, an estimate of the patient’s share of the cost was generated.”

If patients made an overpayment, it was refunded, Accretive wrote. By using Accretive software, policies, and procedures, estimates improved and the number of refunds to patients fell by 60 percent.

Did Accretive employees request or discuss payment or attempt to collect past debts from patients while they received medical treatment or were interned at the hospital? Did they do so for emergency room patients? Patients in the neonatal intensive care unit (NICU)? Were Accretive employees directed to “collect at bedside post patient assessment,” as the report alleges?

The answer to all was “yes,” but within very strict guidelines, Accretive wrote. If patients were stable, if they did not suffer from a life-threatening illness such as heart conditions, if the medical staff had no objections, and if these conversations did not take place at registration, then hospital revenue cycle staff would meet with patients at bedside. “All conversations were optional,” Accretive wrote.

“We believe that Revenue Cycle employees worked to communicate with patients with the greatest possible compassion, in a manner appropriate to the patient’s individual situation,” Accretive wrote. “The goal of these discussions was to help patients understand their cost of care and assist them (if necessary) in obtaining thirdparty coverage for that care. Accretive Health’s corporate code of conduct mandates that each employee commit to delivering services in an ethical, professional manner, and that all patients are treated with respect and dignity.”

What specific medical data did Accretive make available to its post-treatment debt collection agents? The report alleges that “patient health information was used to collect debts.” How exactly was patient health information used to collect debts?

Accretive reported that early in its relationship with Fairview, it relied on Fairview’s patient data system for information about debts owed by patients which did, indeed, contain detailed information about patients. However that system was replaced by Accretive’s software. In all cases, the only information Accretive used was that relevant to what the patient owed.

The report states that Accretive debt collection agents identify themselves as “financial counselors” as opposed to “debt collectors” when seeking payment for past debts from patients.

“While the Revenue Cycle employees in the call center working to collect payments from patients typically referred to themselves as patient financial advisors or debt recovery specialists, these employees also may have from time to time identified themselves as financial counselors,” Accretive wrote.

Sen. Franken asked numerous questions about the stolen laptop and other missing laptops reported by Accretive. All but one laptop was encrypted, Accretive replied, and that was due to the oversight of a single employee in its IT organization who has since been fired. Accretive has put into place new policies and procedures to insure redundancy to make certain all laptops are encrypted.

Finally the senator asked if Accretive believes it has been compliant with federal Emergency Medical Treatment and Active Labor Act (EMTALA), the Fair Debt Collection Practices Act (FDCPA), the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH), and the company responded that it had.