The San Antonio Metropolitan Health District clinic implemented a new fee collection process that increased weekly revenues from around $900 to nearly $5,000. They standardized the language used by staff and asked patients to pay their full bill or what they could afford. However, revenues decreased after the staff member overseeing the process changed roles and the clinic reverted to the old practices due to a lack of formal procedures. Key lessons included designating an owner of the process and creating formal policies to sustain changes.

1. Fee Collection at the San Antonio
Metropolitan Health District
Lessons from the Field

2. Fee Collection at the San Antonio Metropolitan Health District
Lessons from the Field
Nikki Trevino
This publication was funded by a cooperative agreement by the Office of Population Affairs, within the Office of the
Assistant Secretary for Health in collaboration with the Division of STD Prevention within the Centers for Disease Control
and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention.

3. Fee Collection at the San Antonio Metropolitan Health District: Lessons from the Field—March 2014 3
Acknowledgements
San Antonio Metropolitan Health District
Cardea extends thanks to the San Antonio Metropolitan
Health district and its staff for sharing their experience.
Charlene Ransome, STD/HIV Branch Manager
Celia Tejeda, Clerical Supervisor
Cardea
Sandy Rice, MEd, Vice President
Graphic Design: Eric Wheeler
For more than 40 years, Cardea has provided training,
organizational capacity building, and research and evalu-
ation services to improve organizations’ abilities to deliver
accessible, high quality, culturally proficient, and compas-
sionate services to their clients.
Cardea serves as the STD-related Reproductive Health
Training & Technical Assistance Center (STDRHTTAC)
for U.S. Public Health Service Regions VI, IX and X.
Cardea has developed this case study as part of a resource
portfolio to support public health programs with third-par-
ty billing for sexually transmitted disease (STD) and other
related services. Along with this and other case studies, the
portfolio will include:
• Webinars and other resource materials
• An online learning community to facilitate
peer learning
• Customized training and technical assistance
Contact us for more information:
Region VI: srice@cardeaservices.org or 512-474-2166
Region IX: breyes@cardeaservices.org or 510-835-3700
Region X: eedelbrock@cardeaservices.org or 206-447-9538
www.cardeaservices.org

4. Fee Collection at the San Antonio Metropolitan Health District: Lessons from the Field—March 2014 4
Introduction
Public health systems, including state and local STD pro-
grams and public health laboratories, are adapting to the
changing health care environment. While these programs
have historically relied on public funding to support the
provision of free and low-cost health care services, funding
has changed in recent years. With the impact of the Patient
Protection and Affordable Care Act (ACA), programs
are looking to Medicaid and other third-party billing to
sustain services.
Public health programs seeking to bill Medicaid and
other third-party payers for STD-related services face
unique challenges. Policy and systems barriers, resource
and capacity limitations, varying levels of leadership and
staff buy-in, and concerns about billing for public health
services often pose obstacles to implementation of billing
in a public health setting. Case studies offer an opportunity
to highlight the experiences of public health programs that
have faced these and other challenges.
Cardea — Stages of Change Revenue Cycle Management Continuum
Implementation of revenue cycle management (including fee collection and third-party billing) is one of many
changes facing public health programs as they adapt to a changing health care environment. Developed by Drs.
James Prochaska and Carlo DiClemente, the Transtheoretical Model (TTM) of behavior change, otherwise
known as the Stages of Change, can be adapted to identify benchmarks of organizational capacity building for
revenue cycle management. TTM describes the change process along a continuum of five stages: precontem-
plation, contemplation, preparation, action, and improvement/maintenance.
In the action stage, organizations may take one of three pathways: 1) billing a single payer, 2) billing at least two
payers, or 3) billing all major payers. Organizations that begin charging patient fees only or billing only one or two
payers may need to return to the preparation stage as they modify systems.

5. Fee Collection at the San Antonio Metropolitan Health District: Lessons from the Field—March 2014 5
Case Study: Fee Collection at the San Antonio Metropolitan
Health District
Lessons Learned —
Precontemplation/Contemplation
• The need for consistent policies and procedures to
support increased fee collection was clear. If staff
are trained to collect fees in the same way and
monitored for consistent implementation of the
procedure, increased revenues are possible. Standard
procedures for fee collection are also a critical
component of quality improvement and quality
assurance processes in your overall revenue cycle
management process.
• Determining where increased revenue in your clinic
will be applied (overall general fund/operational
expenses or program funds) is important. If funds
will be available to directly support your services,
this may add motivation to make changes in the fee
collection process.
• Fee collection is best done when a private space
to discuss financial issues is available. This
insures patient privacy as well as an opportunity
to speak clearly with patients about their fees and
ability to pay.
Considering a New Strategy
Prior to November 2012, the San Antonio Metropolitan
Health District (SAMHD) was not collecting a significant
amount in fees for STD services and had not considered
ways to increase revenues. The clinic’s weekly revenue, gen-
erated primarily from a $15 administrative fee for services,
was around $900 per week. The approach to fee collection
varied between staff and no consistent procedure existed
for this process. As patients checked out, some staff asked
patients for the $15 fee. Some also asked “What can you
pay today?” Others, however, told patients that they did not
have to pay at all. Beyond these inconsistencies, the area of
the clinic in which fees were collected was not private. This
resulted in some patients refusing to pay simply because
they overheard the person in front of them say that they
were unable to pay.
This situation takes place in many public health clinics
across the country. However, clinic managers at SAMHD
learned from their administration that increased revenue
collected from services would be put back into their
general fund budget and available to support their overall
program needs. This created a powerful incentive to
consider increasing revenue through fee collection.

6. Fee Collection at the San Antonio Metropolitan Health District: Lessons from the Field—March 2014 6
Getting Started
In an effort to generate more revenue and after doing
some research, the clinic manager assigned one staff
person the role of clerical supervisor. Creating this role
gave the staff person the authority to oversee front office
staff and the fee collection process. The newly-assigned
clerical supervisor made immediate changes to the
process, asking staff to shift from their previous practices
and to try something new. Staff told patients their total
bill for services and waited for patients to respond. This
bill included the $15 administrative fee in addition to the
full cost of services that were not otherwise covered by
another funding stream. Once patients saw the bill, they
either paid the bill or expressed their need for assistance.
At that point, staff were instructed to ask patients, “What
portion of the bill are you able to pay today?” and collect
that amount. Finally, staff informed patients that they
could return to pay the rest of their bill when they were
able to. If patients asked about the collections process,
staff told them there was no formal collections process or
any consequence for not paying the rest of the bill.
Clinic staff were provided on-the-job training to imple-
ment these new strategies. The clerical supervisor coached
them on what to say to patients and how to collect fees.
She also asked each staffer to use the same approach. No
formal administrative process was necessary to implement
this change which made the roll out of this approach
easier and quick to implement. By April, staff at the clinic
were using this new language and approach to collecting
fees from patients.
The clerical supervisor noted that newer, or temporary staff
were more amenable to this, and the more long-time, ex-
perienced clinic staff struggled to adopt the new approach.
However, with consistent reminders, they, too, were able to
implement the new approach.
Lessons Learned — Preparation
• In many clinics, even a simple change in the way fees
are collected may require a more thorough approval
process. Be sure to check with your administration on
the process for making changes such as these.
• This clinic found on-the-job (OTJ) training sufficient
for rolling out this change, but you may find that
formalizing the training process and creating
a written procedure for the change will insure
consistency in staff practices.
• The role of the clerical supervisor was critical in this
process. Her ability to work directly with front office
staff and monitor the implementation of this change
was a key reason they were able to get started
quickly and maintain consistent implementation.
Further, her work with the more experienced clinic
staff helped insure all staff were implementing the
change.

7. Fee Collection at the San Antonio Metropolitan Health District: Lessons from the Field—March 2014 7
Implementation
On the first day of implementing this new process, the
clinic was able to collect over $1000, topping their normal
revenues for an entire week. Revenues increased to nearly
$5000 per week—roughly five times the normal revenue
for the clinic. After that success, it was clear the new
process was working.
The clinic manager estimates that many of the clients paid
their entire bill with roughly 25% returning to complete
payment of a bill. The clerical supervisor reported that
some patients seemed to feel a sense of pride and satisfac-
tion about paying their bill. While a few regular patients
complained about the increased fees, most patients did not
complain at all. The change did not impact the number of
clients seen as staff were clear with patients about the new
process and fees, while still providing flexibility for those
who could not pay.
The clinic accepted cash, checks, or credit cards for pay-
ment of services in addition to Medicaid and Medicare.
No patients were denied services due to their inability to
pay any portion of the bill. The lack of a private payment
area continued to present challenges in fee collection and
patient privacy; however, the clinic had plans to move to a
new facility that would have a private check out area.
Lessons Learned — Action
• Designate a staff person to oversee or ”own” the
change process.
• Be clear and upfront with patients about the new
process while still leaving door open for flexibility
in payment.
• A more private check out area can improve fee
collection and ensure patient privacy.
Sustainability and Challenges
While the clerical supervisor was in her new role, this
process was implemented with consistency. However,
shortly after this new approach was implemented, changes
were made to the overall clinic structure and the clerical
supervisor was moved into a new role. While some staff
continued to use the new approach, many of the long-time
employees reverted back to the old process. The lack of a
formalized procedure (or “script” for the new process) and
method for training staff on this process was cited as a key
factor in the inability to sustain this change process.
The change in roles for the clerical supervisor also meant
that there was no one to “own” the process and insure staff
were implementing the change with consistency. While
revenues have continued to be higher than they were before
the new process was implemented, they have decreased due
to the clerical supervisors’ role not being sustained.
Lessons Learned — Sustainability and Challenges
• Create new procedures with input from staff at
all stages of the change to increase ownership by
all staff.
• Designate a staff person to oversee or ”own” the
change process and cross-train an alternate.
• Train clinic staff on new policies/procedures through
both on-the-job and formal training.
• Create a process for staff to voice their concerns
or ideas about the process to increase buy-in and
support maintenance of the change.
• Communicate with upper management about the
change process and the critical aspects that are
needed for success to prevent restructuring that
threatens the sustainability of the change.
• Document key performance measures and successes
such as increased revenue, patients seen, etc.

8. Fee Collection at the San Antonio Metropolitan Health District: Lessons from the Field—March 2014 8
Conclusion
While the lack of sustainability for this change would
indicate it was not successful, the lessons learned in this
example provide valuable insight into how simple the
change was to make and the key factors that contributed
to the success. Sometimes a failure results in stronger
learning and a better ability to implement a change with
more success. When we interviewed the staff at SAMHD
in November 2013, they were making plans to move into a
new facility in 2014 and hoped to be able to make the nec-
essary changes to implement this process again with more
success. They felt strongly that improving revenue through
increased fee collection was possible for other public
health clinics and encouraged others to implement this
approach with the key lessons learned from their attempt.
For clinics that are facing sustainability challenges and
wondering where to start in making improvements to their
revenue cycle management process, a simple change to
fee collection can be a great first step. If increased revenue
from fee collection can be used to support improvement
or expansion of programs, it may be a critical first step in
obtaining some of the more expensive and complicated
systems needed to begin billing third party payers.