Greetings NOHIIN Program Participants!

Transcription

1 Greetings NOHIIN Program Participants! Welcome to our 2 nd webinar of the fall series Demystifying the Sliding Scale Fee Schedule There is always a lot of discussion around the Sliding Fee Schedule and how to structure it to be HRSA compliant. This webinar will help you better understand the general requirements in accordance with the new HRSA Compliance Manual. We will discuss the key elements that are needed in order to make informed decisions about your fee schedule, sliding fee discount, nominal fee and how they work in conjunction with each other. We will also discuss how to handle lab charges, multiple sliding fee discount schedules, as well as patient payment incentives and what to do when a patient refuses to pay.

2 Our 3 rd webinar of the fall series will be Developing Interprofessional Practice Presented by Dr. Sean Boynes Thursday, November 9 at noon eastern time More info to come!

3 After this Webinar: CE Credits and Evaluation Form 1. You will receive a SurveyMonkey link to the CE quiz In order to receive CE Credits, please use Completion Code: You will also receive an Evaluation Form so we can obtain feedback on the effectiveness of this session, as well as potential topics for future sessions

4 Demystifying the Sliding Fee Discount Schedule - Fee Schedules, Sliding Fee Discount Schedules, Nominal Fees and Billing/Collections October 12, 2017 NOHIIN Fall Webinar Series

5 Dori Bingham Program Manager, Safety Net Solutions DentaQuest Institute Associate Vice President, Morton Hospital and Medical Center, Publications Coordinator, Norwood Hospital, Freelance Editor, President, Board of Directors, Taunton Oral Health Center, 2008-present Member, National Network for Oral Health Access Member, American Association of Public Health Dentistry Associate Member, Association of State and Territorial Dental Directors 5

6 Learning Objectives for this Lecture: Identify the general fee schedule/sfds requirements in accordance with the new HRSA compliance manual Recognize key elements of making informed decisions on fee schedules, sliding fee discount schedules, nominal fee & how they work in conjunction with each other Determine how to handle lab charges, multiple sliding fee discount schedules, patient payment incentives and when patients refuse to pay 6

7 I do not have relevant financial relationships with commercial interests.

8 Applicability Applies to all 330 Program grantees and look-alikes Only applies to services/activities within the health center s federally approved scope of project The HRSA Compliance Manual is the only guidance that governs fees, sliding fees and nominal fees at this time: nual/index.html HRSA Compliance Manual supersedes PIN

9 So What s New? A lot less verbiage!!!! A little more clarity Health centers not mandated to reassess patient eligibility for SFDS annually (can determine process and frequency for themselves) Health centers don t have to evaluate their SFDS program annually (needs to be done at least once every three years) Part of this evaluation should include documentation of the patient utilization rate within each discount pay class (as well as at/below 100% FPG)

10 So What s New? Variety of methods can be used to assess whether the SFDS is a barrier to care (eg, utilization pay discount pay classes, patient satisfaction surveys, focus groups, specific surveys for nominal fee patient, Board feedback) Specifies that health centers can have more than one SFDS based on services (eg, dental, medical, behavioral health) OR subcategories of service types (eg, preventive dental vs. restorative dental)

11 So What s New? Health center has leeway in deciding how to inform patients of the availability of sliding fee discounts Documentation of staff training in SFDS not required for compliance

12 General Requirements Health center must prepare a schedule of fees or payments for its services consistent with locally prevailing rates or charges and designed to cover reasonable costs of operation No patient shall be denied service due to inability to pay The sliding fee discount program incorporates the most recent Federal Poverty Guidelines (FPG)

13 General Requirements Eligibility for the sliding fee discount program is based only on family size and income no other factors No specific requirements for how often patients need to be assessed/reassessed for SFDS eligibility (used to be annually) Health center must prepare a corresponding schedule of discounts (SFDS) applied to the payment of fees adjusted on the basis of the patient s ability to pay Health center must establish systems for determining patient eligibility for SFDS

14 General Requirements Full discounts to individuals and families with annual incomes at/ below 100% of Federal Poverty Guidelines (FPG) unless the health center elects to have a nominal charge (which must be a flat fee) Partial discounts for those with incomes between 101% and 200% of FPG No discounts for patients with incomes over 200% of FPG At least three discount categories between 101% and 200% of FPG

15 Federal Poverty Guidelines 2017 Poverty Guidelines for the 48 Contiguous States and the District of Columbia Persons in family/household 1 $12, , , , , , , ,320 Poverty guideline For families/households with more than 8 persons add $4,180 for each additional person; different poverty guidelines for Alaska and Hawaii

16 Governing Board Oversight Health center must have Board-approved policy(ies) for its sliding fee discount program that applies uniformly to all patients Following areas must be addressed: 1. Definitions of income and family 2. Affirmation that eligibility for SFDS will be based only on family size and income 3. Specify methods used to assess eligibility (eg, documentation required, how often eligibility will be assessed) 4. Define how the SFDS will be structured to ensure compliance with HRSA guidance 5. If a nominal fee is charged to patients at/below 100% FPG (as opposed to full discounts), the methods used to determine that the fee is nominal from the patient s perspective (eg, patient surveys, patient Board member input, etc.)

17 Fee Schedule The health center must assure that fees are set to cover reasonable costs of operation and are consistent with locally prevailing rates or charges for the service The health center s fee schedule must address all in-scope services (required and additional) The health center uses data on locally prevailing rates and health center costs to develop and update its fee schedule (health center has latitude in choosing what data to use)

18 Fee Schedule The health center must assure that fees or payments will be reduced or waived to assure that no patient will be denied such services due to their inability to pay for such services (the circumstances related to waivers should be spelled out in policy format and approved by the Board) Can require self-pay patients to pay lab charges out-ofpocket (must inform patients of these charges prior to the time of service) Health center has latitude in what/how to charge patients for these lab fees (eg, at cost, discounted)

19 Fee Schedule The health center can bundle fees for services vs. charging per procedure (eg, preventive visit, emergency visit)

20 Sliding Fee Discount Schedule (SFDS) All services within the health center s approved scope of project, whether required or additional, must be provided on a SFDS Once established, the SFDS must be reviewed and updated at least once every three years (was formerly required annually) Eligibility for the SFDS is based on a patient s annual income and family size under the U.S. Department of Health and Human Services (HHS) annual FPG

21 Sliding Fee Discount Schedule (SFDS) SFDS must be compliant (eg, nominal fee or no fee for patients at/below 100%, at least three discount levels between 101% and 200%, full fees above 200%) SFDS can be based on services (eg, medical, dental) or subcategories of service types (eg, preventive dental and additional dental ) SFDS can also be based on service delivery methods (eg, one for services provided by the health center and one for in-scope services provided via formal written contract)

22 Determining Eligibility for SFDS Health center has latitude in deciding whether to make patients who refuse to provide documentation for sliding fee scale determination ineligible for discounts Health center can take its patient population into consideration when developing processes related to determining eligibility (eg, availability of documentation for homeless patients) but does not have to Health center has latitude to decide what measures it will take to inform patients of the availability of SFDS discounts (eg, materials in language(s)/literacy level appropriate for patient population, as part of intake process, info on website)

23 Determining Eligibility for SFDS Entire SFDS program should be evaluated at least once every three years (no longer required to do it annually) Evaluate utilization data to determine percentage of patients within each slide category, including 100% FPG Take this and other data (eg, results of patient satisfaction surveys or focus groups, self-pay patient surveys) to ensure SFDS program is not a barrier to care Make changes to the program as needed

24 Determining Eligibility for SFDS An outside grant or subsidy may be applied against the patient s portion of the sliding fee discount (eg, special grants to help subsidize care to patients above 200% FPG)

25 Sliding Fee Discount Schedule Structure Dental nominal fee can (and probably should) be different than the medical nominal fee Health centers can set their own discount schedule, percentage of discounts, nominal fees they charge All in-scope services provided via formal written contracts/agreements must follow HRSA SFDS guidelines (there is language in HRSA responses to comments on draft manual that suggests the wiggle room is in informal referral arrangements ) Health centers are responsible for ensuring that fees for services provided via contractual agreements are compliant with SFDS requirements

26 Sliding Fee Discount Schedule Structure Health centers must have a gradation of discounts for income levels between 101% and 200% (discount cannot remain at a constant level across discount categories) Not permissible to provide a full discount for patients above 100% FPG

27 Establishing and Collecting Nominal Charges Any health center that chooses to establish a nominal charge must ensure that patients are not impeded in accessing services due to an inability to pay A nominal charge must be a fixed fee that does not reflect the true value of the service(s) provided and is considered nominal from the perspective of the patient The nominal charge must be less than the fee paid by a patient in the first sliding fee discount pay class beginning above 100% of the FPG (eg, Slide A is nominal fee, Slide B is patients % of FPG)

28 Insured Patients Who Are Also Eligible for SFDS Important to know your state laws and various insurance plan policies on the application of sliding fee scale discounts Income and family size make many insured individuals eligible for sliding fee discounts too Generally, if allowed, the insurance is billed at their normal rate and the patient s co-pay portion is discounted based on their sliding fee scale percentage Some insurance plans do not allow this, so be sure to check!

29 Multiple Sliding Fee Discount Schedules Health centers can have different sliding fee schedules for different service categories The SFDS must comply with federal rules as to nominal fee, minimal fees, and percentage discounts between 100% and 200% federal poverty levels Only one nominal fee within a single SFDS The board must determine the nominal fee and assure it doesn t create a barrier to care for the lowest income populations

30 Laboratory Charges Costs for items done outside the health centers (3rd party lab charges) are exempt from sliding fee discounts and the actual cost can be charged to the patient The professional services performed within the health center are subject to all sliding fee discount conditions Nominal or minimal fees can be charged to the patient for each visit where lab fees have also been incurred and charged Payment options and lab or separate eligible service costs must be discussed up front prior to services and referenced in written documentation

31 Billing and Collections Requirements Health center must establish systems for billing and collections that specify: Education of patients regarding insurance and thirdparty coverage options available to them Billing third-party insurance or other public or private assistance programs in a timely manner Requesting payment from patients (while ensuring no patient is denied service based on ability to pay)

32 Billing and Collections Requirements Health center must make reasonable efforts to enter into contractual or other arrangements to collect reimbursement from state agencies (Medicaid/CHIP) Health center must make and continue to make every reasonable effort to secure payment for services from patients Any billing options or payment methods (eg, payment plans, grace periods, prompt or cash payment incentives) must be accessible to all patients regardless of income level or sliding fee discount pay class

33 Billing and Collections Requirements Health center must have billing records that show claims are submitted in a timely manner and that patients were charged according to the fee schedule and sliding fee discount schedule (if applicable)

34 Provisions for Waiving Charges Health center must assure that any fees or payments will be reduced or waived to assure that no patient will be denied care due to inability to pay The process for waiving fees must be clearly identified in written policy and applied equally to all users; decisions related to the waiving of fees must be made and/or approved by the governing board

35 Prompt Pay Discounts Prompt pay discounts (usually a discount if payment is made at the time the visit) can be applied as long as these discounts are available to ALL patients This means a prompt pay discount is applied to nominal fees and other sliding fee discount levels Can you afford to do this when you are already discounting fees for sliding fee scale patients? Doesn t this create the idea in patients minds that paying at the time of the visit is discretionary?

36 Refusal to Pay Health centers can elect to limit or deny services based on the patient s refusal to pay Must have board-approved policy that distinguishes between refusal to pay and inability to pay Must notify patients of the amounts owed and time permitted to make payments Must inform patients of the collection efforts that will be taken when these situations occur (eg, meeting with a financial counselor/setting up a payment plan) Must notify patients how services will be limited or denied when it is determined that the patient has refused to pay

37 Actions to Consider Review all intended or provided dental services, performing a cost analysis on each and making informed decisions about scope, nominal fee, and sliding fees in dental Decisions should not be made on guess work, instinct or intuition but should be made using timely, meaningful and accurate data to inform those decisions

38 Key Elements to Making Informed Decisions You need to know how dental costs, staffing, equipment, procedures, and operational expenses impact your program Know HRSA s practice goals for dental programs and service expectations Understand that most health center dental clinics are 1/5th as large in volume as their medical clinics These variances between medical and dental will impact your costs and your sliding fee discount determinants differently than the medical program

39 Key Cost-Related Data to Help Determine Scope of Service Cost per visit (expenses divided by number of visits) Lab, supplies, time and costs for each procedure Reports on services provided by ADA code (transaction report) Calculation of RVUs for all services divided by expenses (determines the cost for each RVU provided)

40 Where is There Wiggle Room? Informal vs. formal referral arrangements In scope vs. out-of-scope services Remember that out-of-scope services will not be covered by FTCA so malpractice coverage will be needed

41 CE Credits and Evaluation Form You will receive a SurveyMonkey link to the CE quiz In order to receive CE Credits, please use Completion Code: 1962 You will also receive an Evaluation Form so we can obtain feedback on the effectiveness of this session, as well as potential topics for future sessions

42 Partnering to Strengthen and Preserve the Oral Health Safety Net