Carolinas HealthCare System PFS Billing and Collection Policy

Transcription

1 1 Carlinas HealthCare System PFS Billing and Cllectin Plicy Created: 08/30/2013 Apprved Versin: 10/19/2017 Revised: 10/31/2017 Applicability This plicy applies t the fllwing Carlinas HealthCare System (CHS) facilities: Carlinas HealthCare System Ansn Carlinas HealthCare System Behaviral Health Charltte Carlinas HealthCare System Behaviral Health - Davidsn Carlinas HealthCare System Cleveland Carlinas HealthCare System Kings Muntain Carlinas HealthCare System Lincln Carlinas HealthCare System NrthEast Carlinas HealthCare System Pineville Carlinas HealthCare System Stanly Carlinas HealthCare System Unin Carlinas HealthCare System University Carlinas Medical Center Carlinas Medical Center Mercy Carlinas Rehabilitatin Levine Children s Hspital Objective The Billing and Cllectin (B&C) plicy supprts the Carlinas HealthCare System s (CHS) gal f assisting patients with the cmplexities f billing third-party insurers, prviding patient specific payment ptins, reviewing uninsured patient s eligibility fr cverage assistance and financial assistance and taking actins cncerning amunts due fr services. CHS plicy is t prvide care fr emergency medical cnditins regardless f the patient s ability t pay and withut cnsideratin f the patient s prir payment histry. CHS des reserve the right t take cllectin actins as permitted by law cncerning balances due frm either the patient r third-party insurer. CHS has the fllwing five majr bjectives fr billing and cllectin: demnstrating CHS s cre value f Caring ; btaining necessary patient specific third-party insurer and persnal infrmatin in advance f any scheduled services; cmplying with third-party insurer plicies and State and Federal regulatins related t billing and cllectin; assisting the patient t navigate the cmplexities f seeking reimbursement frm third-party insurers; and establishing billing and cllectin prcesses cnsistent with industry standards. CHS will achieve these bjectives by implementing the fllwing B&C strategies: maintaining up-t-date patient and third-party insurer infrmatin as prvided by the patient r patient representative.

2 2 assisting patients with verificatin f cverage and wrking with third-party insurers t prvide patients estimates f patient cst-sharing amunts fr scheduled services; prviding varius payment ptins fr patients; establishing reasnable effrts t determine patient s eligibility fr financial assistance prgrams; evaluating and implementing healthcare industry best practices in billing and cllectins; and maintaining a rbust cmpliance and patient satisfactin mnitring prgram. Definitins 1. Average Amunt Generally Billed (AGB): The average f Medicare and all private third-party insurer allwables fr all claims allwed in a 12 mnth perid. 2. Bad Debt: Accunts that have been categrized as uncllectible because the patient has failed t pay fr services rendered and are nt eligible fr CAFA. 3. Elective: Services that, in the pinin f a physician, are nt needed r can be safely pstpned. 4. Extrardinary Cllectin Actin (ECA) any cllectin activity taken against an individual that requires a legal r judicial prcess, invlves selling an individual s debt t anther party, reprting adverse infrmatin t cnsumer credit reprting agencies/credit bureau r denying medically necessary services due t insufficient payment. 5. Financial Assistance Scre (FAS Scre): A scre cmputed by a third-party vendr t prvide a practive, cnsistent, and autmated mechanism t substantiate a patient s financial prfile. The FAS Scre is nt a credit scre, but relies n varius databases with mre than 9,000 surces and 2 billin recrds t determine the likelihd that a patient lives in pverty. A cmpnent f the FAS Scre is a Husehld Incme Index that is calibrated t Federal Pverty Guidelines. Other cmpnents f the FAS Scre include, but are nt limited t, a review f census data, cnsumer transactin histry, asset wnership files and utility files. 6. Husehld Financial Incme: An assessment f a patient s incme, as measured against annual Federal Pverty Guidelines, that includes, withut limitatin the fllwing: Annual husehld pre-tax jb earnings Unemplyment cmpensatin Wrkers cmpensatin Scial Security and Supplemental Security Incme Veteran s payments Pensin r retirement incme Other applicable incme, including fr example, rents, alimny, child supprt and any ther miscellaneus incme regardless f surce 7. Third-party Insurers: Any party insuring payment n behalf f a patient, including: insurance cmpanies, wrkers cmpensatin, gvernmental plans such as Medicare and Medicaid, State/Federal Agency plans, Victim s Assistance, r third-party liability resulting frm autmbile r ther accidents. 8. Uninsured: Patients wh are nt cvered under a third-party insurer.

3 3 Plicy Pre-Service CHS encurages each patient t pay based n their ability t pay all r a prtin f the patient s estimated balance fr medically necessary services prir t the scheduled service. The CHS Pre-Service team may cntact the patient t btain third-party insurer and ther infrmatin needed t bill fr services and may prvide an estimate f the patient s ut-f-pcket expenses. Fr insured individuals, the estimate is based n the determinatin f the patient specific third-party cverage fr the services. The CHS Pre-Service team may request that the patient pay all r a prtin f the estimated patient balance. If the patient is uninsured, the estimate f the patient s balance is based n the amunt after the CHS uninsured discunt is applied. Cverage Assistance and Financial Assistance Cverage Assistance and Financial Assistance (CAFA) is available t all uninsured Nrth Carlina and Suth Carlina patients receiving medically necessary services in CHS facilities. CHS fllws tw different prcesses based n place f service when determining eligibility fr financial assistance fr uninsured patients. Categry I is fr all patients receiving inpatient r utpatient services with a patient balance greater than r equal t $10,000 wh are reviewed fr CAFA by the Financial Cunseling Department. A financial cunselr will interview the patient and determine if the patient is eligible fr ther cverage pprtunities. If a patient fully cperates with this prcess and n cverage is available, the patient s accunt will be evaluated fr financial assistance based n the patient s husehld financial incme as cmpared t federal pverty guidelines (FPG). Any patient balance due, if any, will be less than the average amunt generally billed as defined belw. T further assist these patients, interest-free payment plan ptins are available fr any remaining balance. Categry II is fr all patients receiving any ther utpatient services resulting in a patient balance less than $10,000 wh are autmatically reviewed fr financial assistance. Each accunt is autmatically reviewed fr a financial assistance discunt prir t billing. Eligibility is based n a Financial Assistance Scre (FAS) frm a third-party vendr that indicates the likelihd a patient lives in pverty. Patients with qualifying accunts will be extended a 100% adjustment and will nt receive a bill. A patient fund ineligible autmatically will be extended a 50% uninsured discunt. Thse ineligible can als apply fr a manual review by dwnlading an applicatin n the CHS website. Fr Emergency Department services, CHS will request a $75 cpay at the time f service. CHS will review balances incurred thrugh the Emergency Department greater than $75 fr financial assistance thrugh ne f the abve prcesses based n the patient balance. CHS will make reasnable effrts t cmmunicate the CHS CAFA plicy t uninsured patients and determine eligibility fr the CHS CAFA prgram prir t any extrardinary cllectin actin. Reasnable effrts include: 1. Wide publicatin f the CHS CAFA plicy and plain language summary f the plicy t include n the CHS website, at CHS facility admissin ffices and n billing statements 2. Applicatin accessible fr dwnlad n the CHS website r available by mail upn request 3. Multiple language translatins f CAFA plicy, plain language summary and applicatin available n the CHS website 4. Oral ntificatin f the CHS CAFA plicy by PFS Custmer Service and/r third-party cllectin agencies 5. A minimum f 3 billing statements. Plain language summary is included with all billing statements.

4 6. 30 day ntice is sent t patients ntifying them f their financial bligatin, pending cllectin actin and infrmatin regarding the CHS CAFA plicy prir t cllectin agency referral r an extrardinary cllectin actin (ECA) ccurring. Ntice includes the plain language summary. 7. Autmated Financial Assistance Scring (FAS) presumptive eligibility prcess prir t patient billing fr uninsured patients. Thse wh are fund ineligible are ntified via a letter with the plain language summary detailing hw t apply fr CAFA shuld they feel their FAS based eligibility was nt accurate. 8. CHS prvides all patients with 240 days frm the first pst-discharge bill date t apply fr financial assistance prir t any extrardinary cllectin actin. All patients have 30 days t make financial arrangements regarding their bill befre an ECA will ccur whether within the 240 day windw r utside the 240 day windw. 9. All ECAs will be suspended if an applicatin fr CAFA is received during the 240 day applicatin windw r 30 day ntice perid. ECAs will nt resume until a financial assistance determinatin has been made and the patient is fund ineligible fr financial assistance. ECAs will be reversed fr any patient fund eligible fr financial assistance. Patients wh submit incmplete applicatins will als have their ECA suspended and will be ntified in writing f the needed infrmatin t cmplete their applicatin and given 30 days t prvide that infrmatin. 10. The CHS Unified Business Office has the final authrity in ensuring reasnable effrts have been made t cmmunicate the CHS CAFA plicy and determine an individual s eligibility and whether an ECA can be initiated. Average Amunt Generally Billed CHS will never bill any financial assistance eligible individual mre than the average amunt generally billed (AGB). CHS uses a lk-back methd t determine AGB based n all private insurer and Medicare allwables fr all claims allwed within a 12 mnth perid. All uninsured patients autmatically receive a 50% uninsured discunt. Patients apprved fr financial assistance receive at minimum a 50% financial assistance discunt in additin t the 50% uninsured discunt which ttals a minimum f 75% ff grss charges. If a patient is still respnsible fr any prtin f the bill after all discunts, the patient s bill will indicate hw the patient may btain infrmatin n hw the bill was calculated t be belw AGB. Remaining balances after all discunts are eligible fr the Chice Outreach interest free payment plan ptin described belw. Hardship Settlement Discunt The Hardship Settlement prgram is a discunt prgram designed t assist any Nrth Carlina r Suth Carlina resident wh has had a catastrphic medical event that has resulted in very large hspital bills in cmparisn t the patient s financial resurces. A patient wh has incurred a balance after all third-party payments that is greater than 10% f the patient s ttal husehld financial resurces may be eligible fr a Hardship Settlement discunt. A patient seeking a hardship settlement discunt shuld inquire abut this prgram by calling the custmer service department after receiving the patient s first statement. Patient balances must be greater than r equal t $2,500 t qualify fr a hardship settlement. Initial Billing As a curtesy t patients residing in the United States, CHS bills all third-party insurers n their behalf. CHS will assist the patient with all knwn hspital pre-authrizatins and ther apprvals required fr services as a benefit t the patient. The patient is respnsible, hwever, fr all f the insurer s prerequisites fr cvering services. In situatins when services are denied by a third-party insurer, CHS will assist the patient in any appeal prcess with third-party insurers. Fr insured patients, CHS submits a claim n behalf f the patient t the patient s insurance prvider. If there is a patient respnsibility prtin after the third-party insurer pays r denies the claim, CHS will send the patient a minimum f 3 billing statements indicating the balance wed. 4

5 Fr uninsured patients, CHS autmatically applies a 50% uninsured discunt t grss charges and reviews their balance fr financial assistance. Thse receiving partial financial assistance r are ineligible will receive a bill in the mail. Cllectin f Patient Balances CHS reserves the right t utilize utside vendrs t assist CHS and patients regarding balances due and prcess payment plans. When a balance is wed by the patient, CHS expects full payment and cnsiders the accunt t be Self-Pay. 5 An accunt is determined t be Self-Pay if: There is n third-party insurer n recrd. All expected payments frm the third-party insurers have been received. The patient has been uncperative with the CHS Financial Cunseling Department t determine ther cverage pprtunities r financial assistance in accrdance with the CHS CAFA Plicy. CHS will generate at minimum three billing statements and send it t the physical address n file prvided by the patient r representative. Patients wh have pted fr paperless billing will receive a minimum f 3 ntificatins that their billing statements are available in the MyCarlinas Patient Prtal n the CHS website. Each statement includes a plain language summary f the CHS CAFA plicy regarding cverage and financial assistance. CHS will perfrm Medicaid eligibility checks n all self-pay accunts n behalf f the patient after discharge and prir t cllectin activity. If Medicaid cverage is identified, the accunt will be reclassified t Medicaid frm Self-Pay and billed t Medicaid. The last cmmunicatin will ccur at least 90 days frm the first pst-discharge bill date and will include cmmunicatin t the patient that if there is n actin, the patient accunt will be referred fr additinal cllectin actins in 30 days. This cmmunicatin als includes a plain language summary detailing the CHS CAFA plicy. On each billing statement, it is cmmunicated that an itemized bill can be requested by cntacting the CHS Custmer Service call center at Patients can access the MyCarlinas Patient Prtal n the CHS website and request an itemized bill, ask questins, pay bills, and submit questins t the CHS Custmer Service team. All cmmunicatins 30 days prir t bad debt placement, including ral cmmunicatins by third-party cllectrs, include cmmunicatin f the CHS CAFA plicy. Patient Payment Plans If a patient has the means t pay his r her bill but cannt pay in full, they can set up a payment plan administered by a third-party vendr, AccessOne. Patients can call the CHS Patient Financial Services Custmer Service Department at r AccessOne at t set up a payment plan. Three plans are available: 1. Chice is available t any patient with a balance less than r equal t $10,000. The prgram includes an interest free payment ptin fr up t 24 mnths. 2. Chice 10 is available t any patient with a balance greater than $10,000. The prgram expands the interest free payment fr up t 100 mnths (based n accunt balance). The prgram als ffers a fixed lw interest payment ptin as well.

6 3. Chice Outreach is available t patients wh have a high likelihd f living in pverty. Fr example, a patient may have already received financial assistance thrugh the CAFA r Hardship Settlement Discunt Prgrams, but may still have a balance fr which the patient is respnsible fr paying. Patients wh are fund t be belw 400% f the FPG qualify fr this payment arrangement. Fr accunts with a balance less than $2,500, the minimum payment is set t $25 a mnth until the balance is paid in full. Fr accunts ver $2,500, the minimum payment is set t a percentage f the ttal ranging frm.50% t 1% f the balance due. All patients wh were fund eligible fr financial assistance r a hardship discunt are autmatically eligible fr the Chice Outreach payment plan prgram. CHS als prvides a 6 mnth interest free payment plan administered internally. Refunds: Patient refunds are prcessed within 45 days f the ntice f verpayment. Patients wh are wed a refund will receive a paper check t the address n file. Refunds may als be credited back t the credit card used at the time f payment. Bill Inquiry: Patients wh have questins abut charges n their bill can call the CHS Patient Financial Services Custmer Service Department at A custmer service representative will review the charges with the patient and prvide them with an itemized bill upn request. If the patient still has questins regarding specific charges, the patient may request a charge audit. The Patient Financial Service Medical Audit team will validate the charges billed t the services dcumented in the medical recrd. A reslutin letter will be mailed t the patient regarding the audit findings. Cllectin Agency Referral: CHS may refer certain patient accunts t cntracted third-party cllectin agencies. All cllectin agencies wrking n behalf f CHS are expected t cmply with applicable CHS Billing and Cllectins and CAFA plicies. CHS and/r third-party cllectin agencies may reprt adverse infrmatin t a cnsumer credit reprting agency r credit bureau as a result f n r insufficient payment. Agency placement may ccur n earlier than 120 days frm the first pst-discharge bill date and credit reprting may ccur n earlier than 240 days frm the first pst-discharge bill date. CHS and external cllectin agencies will fllw all regulatins related t healthcare cllectins including the Fair Debt Cllectin Practices Act in cnducting cllectin activities. Cllectin Agency Review: After a patient has received at least three billing statements, an accunt is reviewed fr cllectin agency referral. Prir t the referral, CHS takes the fllwing actin: 6 All accunts are reviewed fr current Medicaid eligibility. Uninsured accunts reviewed fr cllectin agency referral that were nt classified as uninsured at discharge and never reviewed fr financial assistance eligibility thrugh the CAFA r FAS prcess will be reviewed fr presumptive financial assistance thrugh the FAS prcess. Thse fund eligible fr financial assistance are extended a financial assistance discunt and nt referred. Thse fund ineligible are ntified in writing with the CHS CAFA plain language summary with infrmatin n hw t apply fr a full CAFA review. Accunts are nt referred if infrmatin has been btained that wuld assist in reslving the accunt balance prir t further cllectin activity.

7 7 Cllectin Agency Placement: Accunts are autmatically submitted t a CHS cntracted primary cllectin agency. Accunts remain with the primary cllectin agency fr a perid f at least 270 days. The primary cllectin agency will make each patient that they cntact fr purpses f debt cllectin aware f the CHS CAFA plicy. The primary bad debt placement agency will nt credit reprt until 240 days frm the first pstdischarge bill date. Secndary Bad Debt placement ccurs 270 days after primary placement fr all accunts that have had n r insufficient payment activity. Legal Cllectin Actins Legal actin will be cnsidered if an accunt ges unpaid and reasnable effrts have been made t determine if the accunt is eligible fr CAFA. The CHS Unified Business Office has the final authrity f determining if a legal actin shuld be pursued and reasnable effrts, defined in this plicy, have been made t cmmunicate the CHS CAFA plicy and determine if a patient is eligible fr cverage r financial assistance. Legal actin will nt ccur until 240 days frm the first pst-discharge bill date. Patients will be given 30 days ntice befre a legal actin ccurs. The 30 day ntice will include a plain language summary detailing the CHS CAFA plicy and all subsequent cmmunicatins will infrm the patients f the CHS CAFA plicy. Patients have 30 days frm the date f the ntificatin t apply fr a CAFA review r reslve the debt befre the legal actin ccurs. If a patient is fund eligible fr cverage r financial assistance after a legal actin has been initiated, legal actin will be temprarily ceased and cverage assistance will be initiated r financial assistance discunts will be applied. Unfrtunately, legal actin is required t encurage a very small minrity f patients t respnd and cperate with the cverage assistance and financial assistance prcess. All CHS legal actin is cmpliant with applicable state and federal legislatin. Legal actins are utlined belw: Small Claims Cllectins accunts with balances $300 - $5000 may be referred t lcal Cunty small claims curt. Lawsuits Accunt balances >$5000 may be referred t an attrney fr pursuit f judgments accrding t apprpriate state laws. Suth Carlina (SC) Tax Debt Set-Off Wrking thrugh the S.C. Assciatin f Cunties, CHS files a set-ff claim against any SC tax refund due the patient. VP Apprval SVP Apprval Date Date