ER doctor, nurse ... and debt collector?

A Chicago-based consultant hired by the Fairview health system pushed hospital workers to engage in overly aggressive bill collection tactics that included pressuring patients in the emergency room, according to an investigative report released Tuesday, April 24, by Minnesota Attorney General Lori Swanson.

Accretive Health Inc. imposed quotas on hospital personnel to collect money before treatment was provided in some cases, according to Swanson's report, and ignored concerns from some Fairview workers that the tactics were going too far.

The report described Accretive's methods as being akin to those "commonly utilized in high-pressure boiler-room-style sales atmospheres."

In a statement, Accretive said it has "a great track record in helping hospitals enhance their quality of care." The work has included helping more than "250,000 patients get insurance coverage," the company said.

Fairview says it stopped using Accretive Health as a debt collector in January and last month decided to terminate a "revenue cycle" contract in which the company directed hospital workers on everything from patient registration and admissions to scheduling and the billing process.

"We share some of the concerns raised by Attorney General Swanson," said Ryan Davenport, a Fairview spokesman. "We've taken actions to address these concerns."

Accretive Health still consults with Fairview on certain health insurance contracts. The company has revenue cycle contracts with more than 60 hospitals across the country, the report states.

In January, Swanson filed a federal lawsuit against Accretive in connection with the theft July 25 of a laptop computer that an employee left in a locked car in Minneapolis.

The incident potentially jeopardized 23,000 patient records from the Fairview and North Memorial health systems. Swanson argued that Accretive violated state and federal laws on medical record privacy by failing to better protect the data.

Swanson also questioned why Accretive had access to sensitive information, including whether patients had HIV, bipolar disorder or schizophrenia.

Accretive disclosed its changing relationship with Fairview in a regulatory filing last month that estimated a revenue impact of from $62 million to $68 million, or about 6 percent of the company's expected 2012 revenue.

Swanson said Tuesday that her office opened a compliance review of the Fairview relationship with Accretive six months ago. That review led to the report released on Tuesday that described a "culture clash," Swanson said, between the charitable mission of Fairview and the financial focus at Accretive.

After obtaining the Fairview contract, Accretive set out to make the hospital a "numbers driven" culture, the report states. Fairview's emergency room and patient registration staff, for example, were "required to talk about the collection quotas, tossing a ball around to each speaker as they discussed their collection performance," according to the report.

Employees at Fairview Ridges Hospital in Burnsville, the report says, were divided into groups named after NFL teams to create a competitive spirit around the task of raising revenue.

"Fairview emergency room workers state that they got the message that if they don't collect money in the ER, they would be fired," the report says. "The publication of employee collection tallies was so demeaning that Accretive and Fairview personnel jointly noted the negative impact on staff morale and the marginal impact it had on collection efforts."

In emails released with the report, Accretive workers talked about the need to "get cracking on labor and delivery" and celebrated the launch of a new collection process for breast cancer patients.

The report includes a letter from an unnamed Fairview worker who said that patients are "harassed mercilessly" until they are approved for the system's charity care program.

In the emergency room, Fairview workers became concerned that the focus on patients paying their bills threatened to run afoul of a federal statute that prohibits emergency rooms from dumping patients who can't pay.

"Three University of Minnesota physicians complained that patients were foregoing (sic) treatment because of the Accretive collection practices," the report states. "Accretive dismissed the doctors' complaints as 'country club' talk."

In December 2011, an incident at the University of Minnesota Amplatz Children's Hospital prompted a risk management attorney at Fairview to question whether Accretive was violating the anti-dumping statute by seeking to collect money before a medical screening was completed. The statute goes by the initials EMTALA, which stand for the Emergency Medical Treatment and Active Labor Act.

"A front end collector...who works closely with Accretive 'lost her composure' at the attorney, labeling her the 'EMTALA police,' " the report states. "The collector emailed (an Accretive official) and said that the attorney's advice on EMTALA is 'a bunch of bull.' "

The incident shows that some hospital workers at Fairview agreed with Accretive's techniques, Swanson said, while others didn't. More broadly, Fairview freely entered into a contract with Accretive for the revenue cycle work, Swanson said.

But rather than issue fines or otherwise punish Fairview, Swanson said, she is trying to work cooperatively with the health system's board of directors to bring about change.

"They have been very cooperative in looking at these issues," Swanson said.

That's not been true of North Memorial, Swanson said, whose office this month issued a civil investigative demand for documents from the Robbinsdale-based health system.

North Memorial's chief executive officer, Larry Taylor, said in a statement that his health system is "working hard to cooperate" with the investigation.

Hospitals need to collect their bills, Swanson said, but "the ultimate concern here is: To what extent do some of these very aggressive practices get in the way of patient treatment?"