Less than two years after UNC Health Care pledged to ease billing practices some found threatening, the system is again ramping up efforts to collect money from its patients.

As of Saturday, all hospital and physician clinics affiliated with the state-supported health system began asking patients to pay their share of the bill upfront. That includes $15 and $20 co-payments to see a doctor. It also includes big-ticket services such as MRI scans, which under many insurance plans can run into the hundreds of dollars.

UNC Health Care leaders say asking for such payments doesn't conflict with their commitment to be more friendly to patients. In fact, collecting more of what patients owe on the front end will ensure that fewer people get menacing letters, calls from collection agencies or invitations to court, said Karen McCall, the health system's senior vice president for public affairs.

"We won't have to chase people," McCall said.

Patients with financial difficulties may find that they qualify for Medicaid or for free or discounted care under UNC Health Care's indigent care policy, McCall said.

If they don't, they can set up a no-interest payment plan. McCall said no one will be turned away if they cannot pay.

Khalid S. Ishaq, a patient at UNC Health Care's Ambulatory Care Center in Chapel Hill, said he wouldn't think twice about paying a set co-payment upfront. But he's not sure the health system will accurately estimate other charges. Ishaq, 75, said UNC once billed him more than $1,000 when it turned out he actually owed about $175 after Medicare paid its share of the claim.

Common practice

In collecting patient fees upfront, UNC Health Care is adopting what is already common practice among private medical practices and most major health care systems in North Carolina and across the country.

The private, nonprofit Duke University Health System, for example, has been requesting that patients pay their portion of the bill at the time of service for at least two years.

"That is what most everyone in the market does," said Cecelia Moore, chief operating officer of the Duke Patient Revenue Management Organization, which oversees billing and collections for the Duke system.

Collecting the patient's share of the bill has become increasingly important in recent years as health insurance coverage has become less generous. Many patients have deductibles of $500 or more and then pay 20 percent of the bill.

Any hospital that isn't trying to collect is losing a lot of money, said Dr. Allen Daugird, UNC Health Care's senior vice president for ambulatory care. Even relatively small payments, such as physician co-payments, add up at an institution as large as UNC Health Care, which has about 750,000 clinic visits a year. If every person had a $20 co-payment, for example, that is $15 million.

Daugird said UNC Health Care's data suggest that it must collect most patient fees upfront if it is to collect them at all. The chances of collecting payment fall by 60 percent if the system bills the patient after the visit, he said.

State funding limited

Though UNC receives taxpayer support each year, less than 5 percent of the system's nearly $1.4 billion operating budget comes from the state.

UNC was in the early stages of adopting its new collection policy when critics mounted a petition effort that charged it was scaring off the poor -- the very group the system's charitable mission instructs it to help.

The system's flagship, UNC Memorial Hospital, was established in 1947 with a mission to care for all North Carolinians regardless of ability to pay.

In response to the petition, UNC Health Care's leaders added a financial assistance hot line, posted signs advertising the system's financial aid programs and postponed making upfront payments the standard systemwide.

UNC Health Care also has hired additional financial counselors to ensure that anyone who needs help will have someone to walk them through all the options, McCall said.

"We want to make every effort to work with people from the very beginning," McCall said.