1 Caring Hearts Financial Assistance Program

Transcription

1 1 Policy & Procedure Policy Title: Caring Hearts Financial Assistance Program Policy Number: [Policy Number] Location(s): All ThedaCare Department(s): All ThedaCare Entities, Affiliates & ThedaCare Employed Providers Date Last Reviewed: 10/1/2015 Reviewing Body(s): ThedaCare Corporate Compliance & ThedaCare Finance Committee Date Last Revised: 10/1/2015 Approving Body(s): ThedaCare, Inc. Board of Directors via Finance Committee Page 1 of 13

2 PURPOSE: It is the policy of ThedaCare, Inc. ( ThedaCare ) to provide care for all persons regardless of his/her ability to pay for the services. Additionally, no patient shall be denied necessary care on the basis of race, creed, color, sex (gender), national origin, sexual orientation, disability or age. SCOPE: This policy outlines the application process and eligibility determination procedure of the Caring Hearts Financial Assistance Program ( Caring Hearts ) which is applicable to all ThedaCare entities and employed providers for all emergency and other medically necessary care. DEFINITIONS: Amounts Generally Billed ( AGB ) The amounts generally billed for medical services provided to patients with insurance that covers those services. The AGB for emergency and medically necessary services is calculated based on payments received during the prior 12-month period for patients covered by all commercial and Medicare payors divided by the gross charges in ThedaCare s fee schedule. The AGB for all other medical services is calculated based on the average payment of the top three commercial payors. These calculations will be made on a facility by facility basis for ThedaCare s hospital organizations that have separate Medicare provider agreements. ThedaCare s AGB will reflect the lowest percentage. Please see Attachment 2 for the current AGB percentages which will be updated at least annually. Application Period Patient and/or Guarantor must request the Caring Hearts application within 240 days after the first billing statement from the date of discharge. Once requested, the Patient and/or Guarantor must submit the completed application and all required supporting documentation within 60 days from the date the Caring Hearts application was mailed or the application may be denied and collection action pursued. This Application Period is effective for dates of service after 12/30/2014. ( Caring Hearts ) The name of the financial assistance program administered by ThedaCare entities, affiliates and employed providers in compliance with IRS Code 501(r)(4). Caring Hearts Discount - A financial assistance discount in the amount of 25%, 50%, 75% or 100%. This is determined by comparing the Federal Poverty Guidelines with the Household Income and Size. Covered Providers Caring Hearts covers emergency and other medically-necessary care provided by ThedaCare in a ThedaCare facility or location. Please see Attachment 3 for a list of providers that are covered by this policy and for those who are not. Emergency Medical Treatment and Active Labor Act ( EMTALA ) EMTALA is found in Section 1867 of the Social Security Act (42 U.S.C dd) and codifies the federal regulations to ensure public access to emergency services regardless of ability to pay. The ThedaCare EMTALA policies outline the procedures for identifying emergency services in the ThedaCare facility emergency rooms. Extraordinary Collection Efforts This is when a delinquent account balance is reported to a credit bureau which may incur a negative remark on the Guarantor and/or patient s credit record. Page 1 of 13

3 Federal Poverty Guidelines The federal poverty levels issued and updated annually by the U.S Department of Health and Human Services. Financial Documentation ThedaCare will request financial documentation that supports the financial assistance application. This may include but is not limited to the past three months pay stubs, detailed checking and savings account statements, previous year tax return, stocks, IRA statements, and written approval or denial from Medicaid. Guarantor The person legally responsible for payment of a bill. Health Insurance Marketplace Organizations that facilitate structured and competitive markets for purchasing health coverage. The Health Insurance Marketplace, or "Exchange," offers standardized health insurance plans to individuals, families and small businesses. Household Income and Size This is determined utilizing guidelines established by previous year tax return, Wisconsin Medicaid or Health Insurance Marketplace guidelines. Last Resort ThedaCare will provide financial assistance as a Last Resort, or after all other entitlement, relief programs, insurance benefits, and alternate sources of payment, including recovery through probate, are applied. Medically Necessary Any hospital inpatient, outpatient, or emergency medical care that is needed for the diagnosis or treatment of a medical condition, meets accepted standard of medical practice, and is not entirely elective for patient comfort and/or convenience. Non Covered Providers ThedaCare has providers that have a private practice within the ThedaCare facility and are not covered in this policy. ThedaCare also contracts with independent providers to perform services. Please refer to Attachment 3 for a list of providers that are covered under this policy and for those who are not. Plain Language Summary A summary of Caring Hearts that outlines how and where a patient and/or Guarantor can apply for the program. Self-Pay Balance The portion of the patient s bill that the Guarantor is legally responsible to pay after all applicable payments and discounts are applied. Uninsured Patient that is not covered by a commercial or government insurance plan. POLICY: A. Notification and Reasonable Efforts to Determine Financial Assistance Eligibility. ThedaCare and/or contracted third parties collecting self-pay balances on behalf of ThedaCare will notify all customers that financial assistance is available using one or several of the following methods: Page 2 of 13

4 1. Hospital and emergency room admission departments will publicize the availability of and how to apply for financial assistance by posting a Plain Language Summary in a visible location in multiple languages. 2. Hospital and emergency room admission department staff will offer a Plain Language Summary as part of the intake and/or discharge process. 3. Patient billing statements shall communicate that financial assistance is available and how to apply. 4. Guarantor shall receive written notification from ThedaCare, a third party collector or both prior to engaging in Extraordinary Collection Efforts. The notification shall inform the Guarantor of potential collection action and will include a Plain Language Summary to advise the Guarantor of the financial assistance option and how to apply. 5. A ThedaCare representative will provide oral communication of the financial assistance program if a hardship is identified when talking with Guarantor via phone. 6. ThedaCare shall not pursue Extraordinary Collection Actions prior to 120 days after the first billing statement post- discharge unless financial assistance eligibility has been determined. 7. The Plain Language Summary shall be posted on the ThedaCare web site and will be included in at least one post-discharge mailing. B. Covered Services. All services, including emergent and medically necessary, are covered with the following exceptions: 1. Services which are communicated to the patient/guarantor and/or paid prior to the service. 2. Services rendered by a Non Covered Provider. Non-Covered Providers are outlined in the definition section of this policy. C. Emergency Medical Services. Services provided in a ThedaCare Emergency Department will comply with the regulations included in EMTALA. D. AGB. ThedaCare will limit the amounts charged for any emergency or other medically necessary care it provides to a Caring Hearts-eligible individual to not more than AGB. E. Last Resort. Caring Hearts shall be the Last Resort after all other relief, entitlement, insurance, litigation, estate recovery through probate and third party liability options have been exhausted. 1. Assignment of any and all health and liability insurance benefits is required before Caring Hearts eligibility can be determined. 2. Insurance benefits paid directly to the insured must be fully reimbursed to ThedaCare prior to consideration for Caring Hearts. 3. All relief and entitlement programs the applicant qualifies for must be exhausted prior to the administration of the Caring Hearts discount. 4. In the event that a ThedaCare patient passes away within 365 days of written notice of Caring Hearts approval, ThedaCare shall have the ability to file a claim against the decedent s probate estate, in an attempt to pursue an alternate source of payment, for the full value of the services provided (i.e. the financial assistance discount applied via the Caring Hearts program shall be reversed). F. Eligibility. To be eligible for Caring Hearts, a patient or Guarantor is responsible to meet the criteria Page 3 of 13

5 outlined below. 1. Complete the Caring Hearts application and provide Financial Documentation within the Application Period. 2. Have an annual household income that is at or below 350% of the current Federal Poverty Level (FPL) as determined by the Federal Poverty Guidelines or the self-pay balance is greater than 15% of total annual gross Household Income. 3. Applicants may be required to complete a screening process with third party specialists to assess insurance eligibility and other financial relief programs. This may include but is not limited to Wisconsin Medical Assistance, Wisconsin Well Woman Program, Indian Contract Health Services, and all other applicable relief or entitlement programs. G. Policy Availability and Publication. You may receive a free copy of this policy by: 1. Visiting the web site. 2. Contacting our Customer Support Department at Mailing a request in writing to: ThedaCare Billing, PO Box 8003, Appleton, WI Requesting copies of the policy at hospital admission and/or cashier areas. H. Caring Hearts Application Process. A qualified ThedaCare Representative will assist applicants through the Caring Hearts application process. Applicants may request additional time to meet the requirements listed below by contacting a ThedaCare customer support representative. 1. The Patient or Guarantor will submit a Caring Hearts application along with supporting Financial Documentation within 60 days from the date the application was mailed by ThedaCare. 2. Collection efforts will cease for 60 days or until eligibility is determined. 3. If the application and all supporting Financial Documentation are not received within 60 days from the date the application was mailed by ThedaCare, the application may be denied and collection efforts may continue unless arrangements are made with a ThedaCare customer support representative. I. Determination of Caring Hearts Eligibility. A qualified ThedaCare Representative will perform a financial assessment to determine eligibility. 1. Based on the initial financial assessment, if it is determined the applicant may qualify for a relief fund, entitlement program or insurance coverage through the Health Insurance Marketplace, the applicant will schedule or complete a financial assistance screening with a third party specialist. The application may be denied if the screening process is not scheduled or complete within 30 days. 2. ThedaCare or the third party specialist will determine Household Income and Size. 3. Discounts will be approved based on the current year Federal Poverty Guidelines. See Discount Table in Attachment 1 for 2015 information. 4. ThedaCare may request additional Financial Documentation to determine Caring Hearts eligibility in its sole discretion. Additional Financial Documentation is often required when the Guarantor is self-employed in order to determine Household Income and Size if it is not provided by Wisconsin Medicaid or the Health Insurance Marketplace. 5. Applicant will not be responsible to pay ThedaCare more that 15% of total gross household income based on annual income. 6. Extenuating circumstances may be reviewed and discounts may be granted on a case by case basis. Page 4 of 13

6 7. If Applicant is determined to be FAP-eligible for care, ThedaCare will refund any amount the Applicant has paid for the care that exceeds the amount he or she is determined to be personally responsible for paying as a FAP-eligible individual so long as amount exceeds $5.00. J. Notification of Financial Assistance Determination. Written notification of ThedaCare s eligibility determination will be provided within 15 business days from the date the complete application was received. 1. Requests for additional information or third-party screening will be sent via mail. 2. Notification of approval or denial will be sent to applicant via mail. Page 5 of 13

7 ATTACHMENT 1: 2015 Discount Table: 2015 Health and Human Services Poverty Guideline Family Size Caring Hearts Approved Discount Percent 100% 75% 50% 25% Percent of Poverty Guideline Income 200% 250% 300% 350% 1 $11,770 23,540 29,425 35,310 41,195 2 $15,930 31,860 39,825 47,790 55,755 3 $20,090 40,180 50,225 60,270 70,315 4 $24,250 48,500 60,625 72,750 84,875 5 $28,410 56,820 71,025 85,230 99,435 6 $32,570 65,140 81,425 97, ,995 7 $36,730 73,460 91, , ,555 8 $40,890 81, , , ,115 Page 6 of 13

8 ATTACHMENT 2: CURRENT AGB CALCULATION The AGB for emergency and medically necessary services is currently 52.1% of gross charges in ThedaCare s fee schedule. The AGB for all other medical services is currently 32% of gross charges in ThedaCare s fee schedule. Page 7 of 13

9 ATTACHMENT 3: LIST OF PROVIDERS Providers Delivering Care at ThedaCare Medical Centers Description: The list below outlines all provider groups delivering emergency or medically necessary care at ThedaCare Medical Centers and specifies which provider groups are covered by ThedaCare's Caring Hearts Financial Assistance Policy. ** For provider groups noted as not being covered under ThedaCare's Caring Hearts Financial Assistance Policy, contact the provider group directly to inquire if they have their own financial assistance policy. Provider Group Name Covered Under ThedaCare's Caring Hearts Financial Assistance Policy?** Advanced Pain Management No X X ThedaCare Medical Centers Appleton Berlin Neenah New London Shawano Waupaca Wild Rose Affinity Heart and Lung Center No X X X X X X Affinity Heart Lung and Vascular Center No X X X Affinity Medical Group No X X X Alexander Eye Institute No X X Allergy and Asthma Associates SC No X X X Apple Creek Oral Surgery LLC No X X Appleton Audiology Associates No X X X Appleton Cardiac Surgery Yes X X X Appleton Cardiology ThedaCare Yes X X X X X X X Appleton Emergency Services Yes X X X X X Appleton Planned Parenthood No X X Appleton Plastic Surgery Center SC No X X Associated Podiatrists No X X Associates in Gastroenterology SC No X X Association of Hospital Anesthesiologists No X X Audiology & Hearing Services No X X Aurora Health Center - Shawano No X Aurora Medical Group No X X X X BayCare Clinics, LLC No X BayCare Orthopedic Surgery Clinic LLp - Kepler No X Bellin Health No X X X X C. Thomas DeRoche, DPM, LLC No X X X Catalpa Health No X X Child Advocacy & Protective Services No X X Children's Dental Health Center No X X Page 8 of 13

10 Children's Hospital of WI No X X Children's Hospital of WI Fox Valley No X X CHN Anesthesiology Clinic Yes X X X CHN General Surgery - Berlin Yes X X CHN Internal Medicine Yes X CHN Medical Center-Berlin Yes X CHN Medical Center-Eastridge, Berlin Yes X X CHN Medical Center-Green Lake Yes X CHN Medical Center-Markesan Yes X CHN Medical Center-Montello Yes X CHN Medical Center-Ripon Yes X CHN Medical Center-Wautoma Yes X X CHN Orthopedic & Sports Medicine - Berlin Yes X CHN Radiology Yes X X CHN Sleep and Occupational Medicine Yes X CHN Urology Clinic Yes X CHN Walk in Clinic-Berlin Yes X CHN Wild Rose Clinic Yes X X Chris M Weinlander MD SC No X X Corey Wesner DPM No X X Daniel McKinnon DDS SC No X X DebJames John Anesthesia No X X X X Dental Associates No X X Dental Haven for Children No X X Dermatology Associates of WI SC No X X X X Dickinson County Health System - Stephenson No X Digestive Healthcare Specialists SC No X X X Dilip Tannan MD No X X Donald Schneekloth, DPM No X X Ear Nose & Throat Specialists of WI No X X X Ear, Nose & Throat Surgical Associates No X X X X X Eye Clinic of the Fox Valley SC No X X X Family Care of the Fox Cities SC No X X First Impressions No X X X X Fox Cities Eye Clinic No X X Fox River Periodontics No X X Fox Valley Autism Treatment Program No X X Fox Valley Chest Consultants No X Fox Valley Dermatology SC No X Fox Valley Emergency Medicine SC Yes X X X Fox Valley Family Medicine Residency No X X Fox Valley Pathologists SC No X X X X X X Page 9 of 13

11 Fox Valley Perinatology SC No X X Fox Valley Plastic Surgery No X X X X Fox Valley Pulmonary Medicine SC No X X X X X Froedtert Memorial Lutheran Hospital No X X Fox Valley Hematology & Oncology No X X X X X X Fox Valley Nephrology Partners No X X X X Green Bay Emergency Medicine Services No X Green Lake Medical Clinic SC Yes X Greenville Foot & Ankle Center LLC No X X X Hand To Shoulder Center of Wisconsin No X X Integrative Pain Management SC No X X Integrity Medical Group SC No X X X Jan C Bax MD SC No X John Dovorany, DDS No X Kagen Allergy Clinic SC No X X Kagen Dermatology Clinic No X X Kaldas Center for Fertility, Surgery, & Pregnancy, SC No X X X X Kaukauna Clinic SC No X X Kennedy Center for the Hip and Knee No X X Kevin Quinn, MD No X X X X Kirtida Ringwala, MD No X X Lakeside Neurocare No X Mark Smith DPM No X Mary McDonald MD SC No X X X Menominee Tribal Clinic No X Ministry Medical Group No X Mosaic Family Health No X X Motion Synergy Physical Therapy L.L.C No X X NE Wisconsin Retina Associates SC No X X NE Wisconsin Vision Center Ltd No X X X Neal Diabetic Foot & Ankle Center No X X Neurological Monitoring Associates LLC No X X Neurology Consultants of Bellin Health No X X X Neuroscience Group of NE WI No X X X X X X NeuroSpine Center of WI SC No X X NEW Anesthesia No X New Dermatology Group LTD No X X North Shore Foot & Ankle No X X Northeast Wisconsin Foot & Ankle Associates SC No X X Ophthalmic Surgery of WI Ltd No X X X Oral & Maxillofacial Surgery Fox Cities SC No X X Page 10 of 13

12 Orthopedic Clinic of Appleton No X X X X Orthopedic Clinic of Appleton/Kenneth Schaufelberger MD No X X X Osteopathic Medicine and Physical Therapy Group of NE WI SC No X X Park West Pediatric Dental Associates, Ltd No X X Partnership Community Health Center Inc No X X Pediatric Rehabilitation Associates, LLC No X X Perinatal Consulting Group Appleton No X X Physio O & P No X Plaza Podiatry Associates LLC No X Premier Health SC No X X Prevea Clinic No X Prevea Health Breast Surgery Experts No X X Prevea Pediatric Neurology No X X Primary Care Associates No X X X Psychiatric Consultants, S. C. No X X Psychology Associates of the Fox Cities No X X PT Center for Women No X X Radiation Oncology Specialists No X X Radiology Associates of Appleton No X X X X X Radiology Associates of the Fox Valley SC No X X X X Ramamohan Turlapati MD No X X X Refine MD No X X Retina & Vitreous Consultants No X X Robert Mann MD No X X Rural Audiology No X Sherman Consulting SC No X X Spine Pain Diagnostics Associates No X Sports Medicine Center, SC No X X St Vincent Regional Surgery Outreach No X St. Elizabeth Hospital CV Services No X X St. Mary's Hospital No X X X Suhasini Turlapati MD No X X X Surgical Associates of the Fox Cities SC No X X X X X The Center for Aesthetics & Plastic Surgery SC No X X ThedaCare At Work Yes X X X ThedaCare Behavioral Health Yes X X X X X ThedaCare Hospitalist Yes X X X X X ThedaCare Medical Oncology Yes X X X X X X ThedaCare Orthopedic Trauma Clinic at Theda Clark Yes X X X Page 11 of 13

13 ThedaCare Orthopedics - Neenah Yes X X X ThedaCare Orthopedics Plus Yes X X X X X ThedaCare Orthopedics Plus - Rheumatology Yes X X ThedaCare Palliative Care Program Yes X X ThedaCare Physicians Yes X X X X X X X Tower Clock Eye Center No X Valley Eye Associates No X X X X X Valley Family Medicine No X X X Valley Neuro/Microsurgery SC No X X Valley Orthopedic Clinic SC No X X X X X Valley Periodontics No X X Vernon Larsen, DDS No X X Vince Lombardi Cancer Center No X Ward Jankus MD No X Waushara Family Physicians - Wild Rose Yes X X X Winnebago County Community Program No X X Winnebago Oral Surgery No X X Wisconsin Colon & Rectal Clinic No X Wisconsin Institute of Urology, S.C. No X X X X X X Wisconsin Michigan Physicians No X X X Wisconsin Oculoplastics LTD No X X Wisconsin Prosthetic & Orthodics No X Wisconsin Veterans Home King No X Women's Care of Wisconsin SC No X X X X Women's Health Specialists SC No X X X X X Women's Specialty Care No X X Zander Dental SC No X Last updated 12/4/15 Page 12 of 13