BILLING AND COLLECTIONS POLICY

Transcription

1 BILLING AND COLLECTIONS POLICY PURPOSE: To provide policies and procedures in regards to patient billing, internal collection practices, and external collection practices performed by an outside agency on behalf of Great River Health System this includes Great River Medical Center and Great River Physicians and Clinics. Great River Health System s billing practices support our commitment to our patients and ensure they are billed in a fair, accurate, and timely manner in compliance with the Patient Protection and Affordable Care Act of POLICY: It is the policy of Great River Health System to only bill for services performed and items used in the care provided. It is also the policy of Great River Health System to assure that all resources are utilized in the billing of our patients and all efforts are made to simplify the billing process as much as reasonably possible. PROCEDURE: Billing Service Codes for services, procedures and products are determined by designated personnel from the Patient Financial Services Department and appropriate department directors. Procedure codes are maintained in the system by Information Systems. Billing Codes and charges for each code is entered in the computerized Patient Billing System and checked for accuracy. PROCEDURE CODE / ADDITIONS / CHANGE 1. When any changes are required or made to Billing Service Codes or charges, the director of the requesting department or designated staff member will initiate the process. These revisions can be completed via on the Procedure Code/Additions/Change form. The Department Director or designated staff member will complete the Procedure Form and route it electronically. The Charge master Analyst will review for completion and accuracy. Once approved, the billing Service Code will be added or edited by the Information System Department. Once completed the completed changes will be sent back to the department director or designated person who initiated the request. The request will be logged and maintained by the Information Systems Department. For departments that may not have access to submit request for additions or revisions of Billing Service Codes, they can submit a hard copy (Procedure Code/Additions/Change Form) to the Charge master Analyst for review and approval. The Charge master analyst will route to the appropriate Information System Representative. Once completed by Information Systems a copy will be submitted back to the appropriate department that initiated the request. CHARGE ENTRY BILLING SERVICE CODES 1. Valid billing service codes may be charged or credited to a patient s account based on usage of the item or procedure during the patient s stay in two ways: a. Documentation and/or alpha billing are used to generate charges for services and / or supplies. b. The charges may be entered directly into the computer by personnel in the department that provides the services using batch charge entry when they are not alpha or document driven. 2. Each department has the capability to review charges daily through the use of charge Administrative Page 1 of 8

2 viewer and should be doing so daily. They also have the capability to enter charges/credits to patient accounts directly from a computer terminal. BILLING PARAMETERS 1. All charges are billed and collected as follows: a. Inpatients are billed three days after discharge. b. Klein long-term patients are billed at the end of each month. c. Outpatients are billed six days after the date of service, or at each month end if the patient is receiving recurring treatment. d. We can file to medical health insurance on behalf of our patients if the following are met: i. The patient or guarantor must provide us with their insurance information which would include a copy of their insurance card(s), their policy number, policy holder, and any additional information required to file insurance. 1. If the patient presents to their appointment without their insurance card(s) and they have insurance other than Medicaid of Iowa, they will be responsible for the bill. The guarantor has 45 days to provide the Health System with the appropriate insurance information in order for us to file. 2. If insurance is not provided or is provided after the deadline then insurance will not be filed if the filing is outside of the insurance company s timely filing rules. This balance becomes the responsibility of the guarantor and if no payment is received the balance could be turned to an outside collection agency. ii. We must have appropriate consent from the patient or guarantor through a signed AOB (Assignment of Benefits) or a COT (Conditions of Treatment) form. 1. If neither of these documents is signed at the time of service, the Insurance Billing staff will make two attempts to reach the patient or guarantor by mail to obtain the appropriate consent. 2. If consent is not obtained within 45 days of the date of service the balance then becomes that of the guarantor as we cannot legally bill your insurance without consent. e. All billing for Great River Medical Center related to Workers Compensation and Auto Accidents are outsourced to a company called MRA out of Tennessee. This billing is handled in house for Great River Physicians and Clinics. i. Auto Accident claims we pursue Med-Pay, which is a no fault insurance. They often pay 100% with no out of pocket. Health insurance is filed after Med-Pay is resolved and any balance over $1,000 is filed to 3 rd party liability insurance. 1. If Med-Pay does not respond within 120 days and the patient has Medicare or Medicaid coverage then the charges are billed to those carriers. 2. If a government payer such as Medicare or Medicaid has been billed we are no longer able to bill Med-Pay. ii. Work Comp will be billed to the employer or work comp carrier provided to us. We request health insurance information in the event that the work comp carrier would deny the claims. If the claim is denied then health Administrative Page 2 of 8

3 insurance is filed. f. Billing for Hospital Based Clinics i. When you see a physician or receive services in a designated hospital based outpatient clinic, you are being treated within the hospital rather than the physician s office. Hospital based billing is the practice of charging for physician services separately from facility charges. Patients may receive two charges on their patient bill for services provided within the hospital based outpatient clinic. ii. Bill all hospital based clinics as place of service code 22 STATEMENTS 1. A monthly self-pay statement is provided to the guarantor of each patient at the point in time the balance is known to be the responsibility of the guarantor. a. The guarantor of an account can be, but is not limited to, a parent of a child under the age of 18, a parent of a dependent child over the age of 18, a spouse of a deceased patient (see guidelines in relation to deceased patients below), or a responsible party not listed above but provided to the Health System. i. The Health System does not take into consideration divorce decrees or other legal documents in relation to support of a minor child. Both parents are held equally responsible for balances of a minor child. Typically the parent that brings the child in for services is the parent named as the guarantor. b. Separate statements are provided for Great River Medical Center and Great River Physicians and Clinics 2. The initial statement is generated the day after the balance becomes the responsibility of the guarantor. It will be itemized and will include the following: a. Itemization of all charges for services performed and care provided b. Dates of service for all services c. Place of Service d. Admitting or attending physician e. Insurance payments and adjustments f. Patient payments and adjustments g. Total balance due by the guarantor 3. The recurring monthly statements are created every 30 days after the initial itemized statement and will include the following: a. A balance forward amount, which is the balance after the last statement b. The encounter date of service c. The encounter place of service d. The encounter admitting or attending physician e. All insurance and patient payments and adjustments that are made after the previous statement. 4. All Great River Medical Center statements include a Financial Assistance Application on the back page. 5. Additional itemized statements are available upon request through the Patient Financial Services Patient Billing office. The itemized statement will be provided to the guarantor within 7 days of the request. It may not be possible for itemized statements to be provided prior to the current year as that is very time consuming and those statements are provided in the initial billing. These requests will be considered on a case by cases basis. 6. Billing in relation to deceased patients: Administrative Page 3 of 8

4 a. A lien will be filed against the estate of the deceased patient if such estate exists. b. In the absence of an estate or in the event that estate assets are exhausted and in accordance with Iowa Code 252A.3: i. A spouse is liable for the medical expenses of the deceased spouse ii. A parent is liable for the medical expenses of a deceased child under the age of 18 years of age iii. A parent is liable for the medical expenses of a deceased dependent child 18 years of age or older. c. At no time will children or family members (other than a spouse) 18 years of age or older be held responsible for outstanding balances of a parent or other deceased family member unless they meet the above criteria. 7. Discounts for Guarantor balances: a. All discounts are based on guarantor balances and not applied to charges that are billed to insurance companies. i. The OIG (Office of Inspector General) opinion states that discounts are acceptable if they are offered to all patients in accordance with the Billing and Collection Policy guidelines and if they are considered as a discount to patients due to the cost savings in relation to billing and collection practices. ii. Per the OIG it is unacceptable to provide a discount to an uninsured patient based on what insured patients receive due to insurance contractual allowances. This would be similar to reducing charges and is considered unfair practice. b. An immediate 10% discount will be applied to all services for patients who do not have insurance. This will be done at the time the charges are added to the patient account. Balances at the time of the first statement will reflect this deduction. i. If it is discovered that the patient had medical coverage at the time of service, then the insurance will be filed and the 10% uninsured discount will be written back onto the account. ii. The uninsured discount will be written back on prior to the account balance being turned to an outside collection agency. c. A 15% Prompt Pay discount will be applied to all balances paid in full prior to or on the date of service. i. These payments and discounts are based on a cost estimate and are subject to final coding. If charges increase or decrease the discount will be adjusted accordingly and the patient may receive a refund or owe an additional amount. d. A 10% Prompt Pay discount will be applied to all balances paid in full after the date of service and within 60 days of the first statement date. PATIENT PAYMENTS 1. It is our policy that all balances are paid in full within 12 months of the date the balance became the guarantor s responsibility, which is the date of the first statement. This means that if the guarantor enters into a payment plan after the first statement the payment plan will be figured for the amount of months that are left in the 12 month period from the date of the first statement. For example, if the plan starts after the 3 rd statement then there are 9 months available for a payment plan. 2. Formal Payment Plans: a. Balances of $300 or less a minimum monthly payment of $25 must be received but is dependent on the aging of the account. Administrative Page 4 of 8

5 b. Balances greater than $300 a minimum monthly payment of 1/12 of the balance or the balance divided by the amount of months left in the 12 month period must be received. c. New balances can be added to an existing payment plan at any time but the plan will not be extended based on the new balance. This means that the final payment month will be that of the existing payment plan and the recurring payments will be adjusted accordingly. d. If the minimum payment requirements are not met then the remaining balance is expected to be paid by the last day of the final month, which is 12 months after the first statement date of the oldest balance. e. If final payment is not received then the remaining balance could be turned to an outside collection agency regardless of whether or not consistent payments are being made. It is the right of the Health System to turn accounts to collection if the terms of the collection policy are not being met. This includes payments that do not meet our minimum payment requirements or balances that are not paid in full by the 12 th month. 3. Employee Payroll Deduction: a. Balances of $325 or less a minimum payment of $12.50 must be received each payroll week but is dependent on the aging of the account. b. Balances greater then $325 a minimum payment of 1/26 or the balance divided by the number of pay periods left in the 26 payroll week period must be received. c. Payroll deduction cannot be created for balances that will be paid off in less than 4 pay periods. d. New charges greater than $50 can be added to an existing payroll deduction. i. New charges that are less than $50 must be paid by other means ii. We cannot add new charges without a new completed payroll deduction form. iii. The final payment of the payroll deduction will be based on the oldest balance. 4. Accepted payment types include cash, check, all major credit cards (Visa, MasterCard, Discover, and American Express), flex card, and electronic checks 5. Ways to pay include: a. By mail with the coupon portion of the statement. b. Through our 24/7 voice pay service by dialing , option 1. You must have your statement number and account number in order to make this type of payment. c. Online at You can also select a Bill Payment from the Patient Portal. d. Over the phone with a Financial Counselor by calling , option 2. e. In person with at Financial Counselor at the Patient Billing office located next to the Gift Shop. f. By acquiring a Medical Expense Loan with the assistance of a Financial Counselor. 6. Great River Health System will accept payments with a notation of Paid in Full but does not consider such payments as an agreement of paid in full: a. Insurance companies have up to 7 years to audit payments and recoup if they find they paid incorrectly. In such an event, the new balance could then become the responsibility of the guarantor and Great River Health System has the legal right to bill the guarantor. Therefore, a previously paid balance with the notation of Paid in Full is considered null and void. Administrative Page 5 of 8

6 b. If the amount paid is less than the balance of the statement and the patient writes Paid in Full the patient will still be responsible for the outstanding balance unless it falls under the prompt pay discount guidelines. PATIENT RESOURCES 1. It is the policy of Great River Health System s Patient Billing department to assist patients with any and all resources that may be available to them. a. This includes resources such as but not limited to formal payment plans, Financial Assistance, qualification of Presumptive Medicaid or full Medicaid, enrollment into HealthCare Marketplace insurance, and enrollment into a medical expense loan. 2. Financial Assistance is available to patients who qualify. Qualification is based on Federal Poverty guidelines. INTERNAL COLLECTION PRACTICES 1. Statements are sent on a monthly basis. 2. Bill reminders through calls, , text, or demand letters are made by Financial Counselors or an outside automated call system. a. The purpose of the reminder is to collect payments for outstanding balances, set up payment plans, screen patients for Financial Assistance, or set patients up with a medical expense loan. 3. If all forms of communication are exhausted and balances remain outstanding then Financial Counselors will mail a demand letter to the patient letting them know of the past due balance and advising them of their options. Administrative Page 6 of 8

7 ASSIGNING OUTSTANDING BALANCES TO AN OUTSIDE COLLECTION AGENCY 1. It is the policy of Great River Health System to exhaust all internal efforts listed above before balances are moved to an outside collection agency acting on behalf of Great River Health System. 2. Balances may be turned to an outside collection agency acting on behalf of Great River Health System in the event the patient does not do one of the following: a. Pay the balance in full within 12 months of the first statement date. b. Comply with an acceptable payment agreement. If a patient is making consistent payments that do not meet the 12 month policy then they could be turned to collection. c. Comply with the Financial Assistance Policy. d. Comply with governmental programs in an effort to obtain medical coverage. 3. Outstanding balances with no payment will not be turned to an outside collection agency until 120 days from the date the balance became the responsibility of the guarantor. EXTERNAL COLLECTION PRACTICES DUE TO NON-PAYMENT 1. Outside agencies acting on behalf of Great River Health System will adhere to any and all rules and regulations in regards to the Patient Protection and Affordable Care Act of Outside agencies acting on behalf of Great River Health System will not impose Extraordinary Collection Actions (ETAs) until reasonable efforts to resolve the debt are exhausted (an additional 120 days must also be exhausted for Great River Medical Center balances). 3. Reasonable efforts include: a. Validate that the patient owes the unpaid bills and that all sources of third party payments have been identified and billed by the hospital b. Documentation that Great River Health System has attempted to offer the patient the opportunity to apply for financial assistance pursuant to this policy and that the patient has not complied with the hospital s application requirements. c. Documentation that the patient has been offered a payment plan but has not honored the terms of that plan 4. Extraordinary Collection Actions include: a. Selling debt to a third party other than a collection agency b. Reporting adverse information to a consumer credit reporting agency or credit bureau c. Filing a claim for an unpaid debt through the court system d. Applying a lien against the guarantor s assets for an outstanding debt PATIENT CONCERNS / COMPLAINTS 1. All patient questions or concerns related to their balance or service provided will be addressed as follows: a. Insurance balances, Coordination of Benefits, Assignment of Benefits, questions related to insurance denials, etc. will be addressed by Great River Health System Insurance Billers b. Questions / concerns related to denials due to coding will be addressed by Great River Health System Coding Specialists. c. Questions in relation to Statements, Guarantor Balances, Financial Assistance, and patient complaints will be addressed by Patient Billing Financial Counselors. 2. If the patient inquiry or concern requires further assessment it can be referred to the Patient Financial Services Director, the appropriate Department Director, Compliance Administrative Page 7 of 8

8 Officer, Quality Resources, Patient Satisfaction Specialist, and/or Administrative VP. 3. The appropriate department will be responsible for making changes, reversals, or corrections. All adjustments or write offs will be completed by the Patient Financial Services department. Administrative Page 8 of 8