FINANCIAL ASSISTANCE POLICYBUS - Financial Assistance Policy

Transcription

1 STATEMENT OF POLICY: Peterson Regional Medical Center shall fulfill their charitable missions by providing health care services to all individuals in our community without regard to their ability to pay. The hospital shall provide a non-discriminatory application process to low income underinsured or uninsured patients. The hospital shall use consistent and fair collection practices for all patients. No patient shall be denied emergency or other medically necessary care based upon their ability to pay, race, color, religion, creed, sex, national origin, age or disability. SCOPE: All services provided by departments of Peterson Regional Medical Center and Peterson Community Care Center. DEFINITIONS: Amounts Generally Billed (AGB): The amount by which charges for uninsured patients are measured. Uninsured patients will not be charged more for emergency or other medically necessary care than the AGB for patients who have insurance. Episode of Care: A defined period of illness that has a definite start and end date. Federal Poverty Guidelines (FPG): Determined by the federal government of the United States and published annually in the Federal Register. FPG are based on the size of the family and family s income. FPG are used in determining a patient s eligibility for financial assistance under PRMC s financial assistance policy. Gross Charges: Full, established price for medical care that the hospital consistently and uniformly charges all patients before contractual allowances, discounts or other deductions. Medical Indigency: Patients who are unable to pay some or all of their medical bills because their medical bills exceed a certain percentage of their family of household income or assets. Special circumstances may include catastrophic costs or conditions. Prompt Pay Discount-Hospital: A 15% discount of the patient s self-pay account balance (including any copayment or deductible) if paid within 30 days of the statement date. This discount is an administrative adjustment and not considered financial assistance. Prompt Pay Discount-Lab: A 50% discount of the patient s self-pay account balance (including any co-payment or deductible) if paid within 30 days of the statement date. This discount is an administrative adjustment and not considered financial assistance. Self-Pay Discount: A percentage discount of the patient s self-pay account balance based on Uninsured status. Under Insured: Those patients with insurance coverage unable to satisfy their out of pocket expenses. Uninsured: A person who does not have insurance or third-party coverage who does not qualify for Medicaid or other state assistance. A patient may be classified as uninsured if the patient is insured, but the insurer refuses to pay for medical services rendered for reasons such as pre-existing conditions, out-of-network provider, etc. 1

2 PROCEDURE: ELIGIBILITY CRITERIA: PRMC provides financial assistance to patients who need emergency or other medically necessary care, but can demonstrate an inability to pay for all or a portion of the amount charged for hospital services. Patients without the financial ability to pay are evaluated for eligibility under Medicaid or other state assisted programs. Patients ineligible for Medicaid or other state assisted programs are then evaluated for financial assistance under PRMC s (FAP). PRMC financial assistance is provided in the form of a FAP discount or as free care. Eligibility for financial assistance to Uninsured and Insured patients with a self-pay balance is based on FPG, income of the patient s household and personal assets. Upon receipt of a patient s completed and signed financial assistance application, proof of income and other documentation as required, the level of financial assistance is determined using a sliding scale based on the Gross Charges or balances due after insurance payment. Patients will meet the financial and documentation criteria defined in this policy for the application to be eligible. All scheduled services including SDC, OR, CCIR, and INPATIENT hospitalization will be required to have a completed application on file prior to the date of service and will be approved on a per episode of care basis. Full charity care shall be provided to under insured patient s deductible, co-pay and out of pocket expenses and uninsured patients earning equal to or less than150 percent of the federal poverty income guideline (FPIG). For financially needy under insured or uninsured patients earning between 151 percent and 300 percent of the FPIG, charity funds shall be provided to limit such patient s payment obligation to the amount of the patient account balance. By subtracting the percentage discount applicable to the patient s FPIG household income provided in the following table, the balance will be patient responsibility. Discount Current Year s Federal Poverty Income Guidelines for Family Size 100% Family income is less than or equal to 150% of FPIG 80% Family income is 151% to 175% of FPIG 60% Family income is 176% to 200% of FPIG 40% Family income is 201% to 250% of FPIG 20% Family income is 251% to 300% of FPIG 0% Family income is greater than 300% of FPIG Peterson Regional Medical Center reserves the right, on a case-by-case basis and at the discretion of the CFO or CFO designee, to extend eligibility for financial assistance to patients who have household incomes that exceed 300 percent of the FPIG and documentation of the special circumstances. Application will be non-discriminatory. 2

3 Patients who meet Presumptive Eligibility Criteria may be granted financial assistance without completing the financial assistance application. Documentation supporting the patient s qualification for or participation in a program must be obtained and kept on file. Documentation may include a copy of a government issued card or other documentation listing eligibility or qualification, or print screen of web page listing the patient s eligibility. Examples of presumptive eligibility include but are not limited to: homeless, deceased with no assets and no estate, balance due after Medicaid or Indigent Health Care payments. The federal poverty income guidelines will be updated annually from updates published by the United States Department of Health and Human Services. In determining whether a patient meets the eligibility criteria for financial assistance, the hospital will consider the extent to which the patient s household has assets other than income that could be used to meet his or her financial obligation. The hospital will also take into account any liabilities that are the responsibility of the patient s household. Assets will include, but not limited to cash, savings and checking accounts, certificates of deposit, stocks and bonds, individual retirement accounts, trust funds, real estate, and motor vehicles. Household income of all adults 21 years or older will be considered in determining whether a patient is eligible for assistance. Household income includes but is not limited to the following: traditional married couples, children (biological, step, or adoption), and couples/partners living together. Financial assistance may be provided to patients who are determined to be medically indigent. The patient shall provide documentation to support his or her medically indigent status including but not limited to: copies of medical bills, information related to patient s drug costs or evidence of healthcare costs for which the patient is responsible. METHOD OF APPLYING FOR ASSISTANCE To apply for financial assistance, patient or legal guardian must complete and sign the PRMC one page application and provide support documentation. Applications are available from Patient Access customer service representatives, Financial Counselors and the PRMC website Financial Counselors are available to assist in completing forms and answer questions. Financial Counselors may be contacted by calling the following numbers for questions and/or appointments for one-to-one assistance: Peterson Regional Medical Center: Peterson Community Care Clinic: Peterson Ambulatory Care Center: Documents to verify income and assets include but are not limited to: Most current year personal and business federal income tax return and related schedules; Copies of two previous months employment pay stub for patient and patient spouse. If minor child, pay stubs of both parents and or legal guardians; 3

4 Copy of any Other Income including but limited to, social security payments, disability income, workman s compensation income, pension payments, unemployment compensation, child support payments, food stamp awards, investment income, annuity payments. Income is considered patient s household gross income or, if self-employed, the gross income less business expenses directly related to producing goods and services. The completed and signed application with related documentation can be mailed to: PRMC Patient Accounts/Financial Assistance Program 551 Hill Country Drive Kerrville, TX Applications may also be dropped off with the hospital cashiers or faxed to Upon receipt of a patient s FAP application, the application will be screened for the required information and documents. Hospital applications are screened by PRMC Financial Counselors and final reviewed by the Charity supervisor. Patients who submit an incomplete application will be contracted whether by telephone or U.S. mail within 20 working days detailing the information needed. Within 10 working days of receipt of a completed application, patients will receive a notification letter. An approval letter will show the percentage Discount from Gross Charges or the balance after insurance [payment and the balance still due from the patient, if any. A Denial Letter will list the reason for the denial. COMMUNICATION OF PRMC CHARITY AND FINANCIAL ASSISTANCE POLICY: The hospital will develop a means of widely communicating the availability of charity care and financial assistance to all patients and within the community served. Examples of mechanisms that the provider may use to do this include: Placing signage, information, or brochures in appropriate areas of Peterson Regional Medical Center (e.g., the emergency department and all registration and check-out/cashier areas) stating that PRMC offers financial assistance and describing how to obtain more information about the program. Documentation on the healthcare bill and statements regarding how to request information about financial assistance. Posting the FAP on the opening page of the website. - Designating Peterson Regional Medical Center individuals who are trained and qualified to explain the financial assistance policy. 4

5 Instructing staff who interact with patients to direct questions regarding the financial assistance policy to the proper provider representative. 1. A patient who qualifies for partial charity will cooperate with the provider to establish a reasonable payment plan that takes into account available income and assets, the amount of the adjusted bill(s), and any prior payments. 2. Patients who qualify for partial assistance will make a good faith effort to honor the payment plans for their adjusted healthcare bills. Patient/guarantor is responsible for communicating to the provider any change in their financial situation that may impact their ability to pay their discounted healthcare bills or to honor the provisions of their payment plans. B. Application Eligibility Period. Every patient/guarantor will be required to complete a new application and submit required documentation every calendar year. Scheduled procedures require application and all documentation to be submitted and approved prior to scheduled visit. 1. The following services will have a 90 day approval period: infusion therapy, physical, occupational and speech therapy, diagnostic services including but not limited to, lab and radiology services and Peterson Community Care Center services. Recertification for charity care will be required 90 days after the approval date. 2. The following services will be approved for charity on a case by case basis per episode of care: inpatient hospitalization including acute rehabilitation, observation, SDC, OR and CCIR. Recertification for charity care will required per each new episode of care. C. Application Approval Procedure. Hospital FAP adjustments will receive the following level of approval: 1. $0-15,000 may be approved by the Business Office Director or Patient Access Director. 2. $15,001-50,000 may be approved by the Chief Financial Officer. 3. $50,001 and higher may be approved by the Chief Executive Officer. BILLING AND COLLECTION PROCEDURES 5

6 A. Insurance coverage for all patient accounts is reviewed within 24 hours of the pre-admission interview or actual admission date (except when the patient is admitted during the weekend). PRMC attempts to meet all managed care pre-certification requirements; however, it is ultimately the patient s responsibility to obtain pre-certification/referral authorization prior to admittance. PRMC will not be held liable if a precertification/referral is not properly obtained, unless PRMC is contractually obligated to obtain the precertification/referral. B. Uninsured patients are screened for eligibility under Medicaid or other state programs as soon after admission as possible. Financial Counselors meet with uninsured patients and patients with deductibles and co-insurance to identify the payment source, to make payment arrangements, and/or to provide information regarding the FAP. Financial counseling is available to all patients to address concerns regarding financial options. C. Co-payment and deductible and/or estimated co-insurance amounts are requested from Emergency Department patients at the time of discharge. Co-payment and deductible amounts (or estimated amounts thereof) are requested from Inpatient, Observation, Imaging and Same Day Surgery patients at preregistration, registration or prior to discharge. D. It is the patient s responsibility to provide Peterson Regional Medical Center with all necessary information to bill the patient s insurance(s). PRMC staff will complete and submit claims on the patient s behalf. Patients will be billed for balances remaining after third-party payments and adjustments are applied. Even though insurance is carried, the patient is ultimately responsible for providing payment for services rendered. If the patient s insurance rejects or denies payment for services, PRMC will bill the patient, unless PRMC is contractually prohibited from doing so. E. The Self-Pay Discount is available to all uninsured patients regardless of their ability to pay, and therefore is not considered financial assistance. If an Uninsured patient receives a Self-Pay Discount and subsequently provides valid insurance information, the Self-Pay Discount will be reversed when PRMC bills the third party. If an Uninsured patient receives a Self-Pay discount and subsequently qualifies for financial assistance, the Self-Pay Discount will be reversed before the FAP Discount is applied so the adjustment is properly classified. F. Uninsured hospital patients are eligible for a Self-Pay Discount based on the most recent AGB. The Discount is provided at the time of final billing and is reflected on the first bill. G. All hospital patients are eligible for a 15% Prompt-Pay Discount if they pay in full within 30 days of their first statement. Prompt-Pay Discounts are classified as administrative adjustments. 6

7 H. Billing functions for Self-Pay balances are performed by PRMC. The patient billing cycle begins with the production of a final bill (in the case of Uninsured patients) or with payment or denial by the insurer (in the case of insured patients). The billing cycle is as follows: Day 1 1 st statement Day 30 2 nd statement Day 40 3 rd statement Day 50 Referred to collection agency Out bound calls are placed throughout the billing cycle and patients are informed of the Prompt-Pay discount on the first billing statement and the availability of financial assistance on all billing statements. I. PRMC establishes and monitors patient payment plans according to the following guidelines: Account Balance Maximum Number of Monthly Payments $0-$50 2 $51-$250 3 $251-$1,000 6 $1,001-$2, $2,501-$5, $5,001-$7, $7,501-$12, requires 8% >$12,001 Patient must secure outside financing or apply for Financial Assistance. Prior to granting a loan to a patient, PRMC will evaluate the credit worthiness of the patient or guarantor. If a loan is granted, the patient or guardian will sign a loan agreement. After the loan is approved, statements are provided on a monthly basis to patients on approved payment plans. Any loan guarantor missing two successive payments will be forwarded to collections. No notification to the loan signer will be issued. Any and all exceptions to the above procedure must be approved by the {Director of Business Office or the Director of Patient Access} and the Chief Financial Officer. J. Patient concerns are handled by the PRMC Business Office Staff or PRMC Financial Counselors. Any unresolved patient concerns are referred to the Business Office Director or the Patient Access Director. If questions regarding patient charges arise, the manager of clinical department is consulted. If there is a material dispute regarding the charges on the patient s bill, the collection process may be put on hold until the dispute is resolved. Write-Offs done as a resolution to patient concern or patient care issue must be approved by the Director of Business Office, Director of Patient Access or Director of Risk Management (up to $25,000) the Chief Financial officer ($25,000 to $50,000) and the President/Chief Executive Officer ($50,000 or more). 7

8 K. Hospital FAP Discounts receive the appropriate level of approval, i.e., the Director of Business office or the Director of Patient Access must approve all hospital Financial Assistance discounts under $25,000, the Chief Financial Officer those over $25,000 and the President % Chief Financial Officer those over $50,000. L. Approved Hospital FAP discounts are processed by the Self-Pay Collections Supervisor. A notification regarding the level of FAP Discount is provided by mail to the patient by on-site staff. M. To make a reasonable effort to determine FAP eligibility for patients who do not submit an application, PRMC will use criteria as defined in the Presumptive Eligibility Criteria portion of this policy. Balances that do not qualify for a discount will be referred to an outside collection agency. N. Any patient who falls outside the PRMC guidelines to receive a discount or whose financial situation has changed, but still feels that they are unable to pay or set up appropriate payment arrangements, can apply for assistance by completing the financial assistance application and furnishing proof of income and assets. These requests will be considered on a case-by-case basis. The same authority as listed in section (K) will apply and Self-Pay Collection Supervisor will process the write-off and notify the patient. O. If a patient receives debt relief under bankruptcy, the account balance is written off and classified as charity. The hospital uses adjustment code ABANKRUPT. If the account is already in a bad debt status and at the collection agency, the same codes will be used to adjust the account using the Bad Debt Recovery journal. These will be reclassified to charity in the General Ledger. P. In addition to financial assistance, the Chief Financial Officer may approve an adjustment to a patient account balance based on goodwill, public relations or risk management concerns, so long as there is no intention to influence patient referrals or induce any federal health care program beneficiary to receive services from PRMC. NON-PAYMENT A. Patients accounts for which no payment has been received and financial assistance has not been requested are referred to a collection agency 50 days after the patient bill is produced. Patients whose accounts have been referred to a collection agency are still able to request financial assistance. REFERENCE: 8

9 2014 Poverty Guidelines Poverty Persons in family/household guideline 1 $11,670 2 $15,730 3 $19,790 4 $23,850 5 $27,910 6 $31,970 7 $36,030 8 $40,090 For families/households with more than 8 persons, add $4060 for each additional person. 9