Financial Assistance Policy. Memorial Hospital of South Bend patients receiving Emergency and/or Medically Necessary Care

Transcription

1 Plicy /Prcedure Dcument Categry/Surce: Originatin Date: 7/1/2004 Plicy Number: Last Review Date: 11/30/2017 Last Revised Date: 01/07/2018 Next Review Due: 01/01/2020 Plicy Owner: Executive Directr f Revenue Cycle Required Apprvals: Chief Financial Officer Bard f Directrs TITLE: Financial Assistance Plicy SCOPE: Memrial Hspital f Suth Bend patients receiving Emergency and/r Medically Necessary Care PURPOSE: POLICY/PROCEDURE: Ensure transparency, cnsistency and fairness twards uninsured (selfpay) patients and set guidelines fr prviding a financial adjustment t any uninsured r underinsured patient wh btains Medically-Necessary r Emergency Services frm Memrial Hspital f Suth Bend. This plicy ensures that Memrial Hspital is cmpliant with the Patient Prtectin and Affrdable Care Act and Internal Revenue Cde sectin 501(r ). This requires tax-exempt hspitals t limit amunts charged t uninsured patients fr emergency and ther medically necessary care t n mre than thse amunts generally charged t insured patients. Screen uninsured patients fr: their ability t pay, pssible eligibility fr health cverage prgrams r third party cverage, and all available resurces in rder t identify charity cases in a timely manner. Health cverage prgrams culd include, but are nt limited t, Medicaid, Medicare Savings Prgrams, subsidized insurance plans purchased thrugh the Marketplace r Affrdable Care Act (ACA) Exchange, r ther state, federal and lcal prgrams. In rder t qualify fr financial assistance an individual must apply and cmply with the applicatin fr any ther pssible payer surce. Prvide prgram applicatin assistance prcedures, the methd fr applying fr Memrial Hspital f Suth Bend financial assistance, the plicy fr the basis f calculating eligibility fr free r discunted care and the actins the hspital may take in the event f nn-payment. Regardless f an individual s ability t pay r qualify under this Financial Assistance Plicy, Memrial Hspital f Suth Bend will prvide, withut discriminatin, care fr any emergency medical cnditin(s) as designated under the U.S. federal gvernments Emergency Medical Treatment and Labr Act (EMTALA) f N persn shall be discuraged frm seeking emergency care. N persn shall be excluded frm cnsideratin fr financial assistance based n age, clr, creed, ethnic backgrund, gender, natinal rigin, physical disability, race r religin.

2 Page 2 f 10 Patients that are uninsured (self-pay) will receive a 35% discunt ff their grss charges. This discunt applies t all hspital services, and is exclusive t any ther discunts r acceptance t the FAP. This FAP applies t services prvided and billed by Memrial Hspital f Suth Bend. It des nt apply t physicians wh may prvide services t patients f the hspital. Please see Attachment 2 fr a list f prvider grups wh are nt cvered by this FAP. In rder t manage its resurces respnsibly and t allw Memrial Hspital f Suth Bend t prvide the apprpriate level f assistance t the greatest number f persns in need, the fllwing guidelines fr the prvisin f financial assistance have been established. Definitins: Amunt Generally Billed (AGB) Memrial Hspital f Suth Bend will apply the "lk-back methd" fr determining AGB. In particular, Memrial Hspital f Suth Bend will determine the AGB fr emergency r ther medically necessary care by multiplying the Grss Charges fr such care by the AGB Percentage. AGB Percentage Memrial Hspital f Suth Bend will calculate the AGB percentage at least annually by dividing (1) the sum f payments n all claims allwed during the 12-mnth perid frm in the prir calendar year by Medicare fee-fr-service and all private health insurers that pay claims t the hspital facility by (2) the sum f the assciated grss charges fr thse claims. Csmetic Services thse services and prcedures that enhance the patient s well-being, are typically nt cvered by any insurance, and are categrically excluded frm any financial r ecnmic assistance. Emergency Services an emergency accident, meaning a sudden external event resulting in bdily injury, r an emergency illness, meaning the sudden nset f acute symptms f such severity that the absence f immediate medical attentin may result in serius medical cnsequences. Or as defined in Sectin 1867 f the Scial Security Act Elective Services Healthcare services and prcedures that are needed t supprt the health and wellbeing f the patient whether r nt they are deemed medically necessary. Such services are eligible fr cnsideratin under this plicy. A physician rder cntaining the reasn fr the test r prcedure may be required. FAP Financial Assistance Prgram as defined in this plicy Grss Charge An established price, listed n the hspital s charge master, fr a service r item that is charged cnsistently and unifrmly t all patients befre applying any cntractual allwances, discunts r deductins. Husehld Unit ne r mre persns wh reside tgether and are related by birth, marriage, r adptin (i.e. parents and children wh are filed as dependents n their tax return); r reside tgether and share jint assets, such as credit cards, bank accunts r real estate. Patients ver the age f 18, such as adult children living with their parents, siblings r friends are nt cnsidered part f the husehld unit unless such persns are legally bligated fr the debts f the patient. Incme Incme includes salary and wages, interest incme, dividend incme, scial security, wrkers cmpensatin, disability payments, unemplyment cmpensatin, business incme, pensins & annuities, farm incme, rentals & ryalties, inheritance, strike benefits, and alimny payments. Incme is als defined as payments frm the state fr legal guardianship r custdy. Medically Necessary fr the purpse f this plicy is defined as a service that is necessary t treat a cnditin that in the absence f medical attentin culd reasnably be expected t result in jepardizing the health r cnditin f the individual. Plain Language Summary A statement written in clear, cncise and easy t understand language ntifying individuals that Memrial Hspital f Suth Bend ffers financial assistance under a FAP. Self-Pay r Uninsured A patient wh des nt have third party cverage frm a health insurance plan, Medicare r state funded Medicaid, r whse injury is nt a cmpensated injury fr purpses f wrkers cmpensatin, autmbile insurance r ther insurance as determined and dcumented by the hspital.

3 Page 3 f 10 Underinsured patient A patient and/r respnsible party with third party cverage fr healthcare service wh may have an extrardinary amunt due that they cannt pay due t husehld unit incme. Financial Assistance Prgram Availability Memrial Hspital f Suth Bend will widely publicize assistance availability using the fllwing methds: At main patient access and registratin pints t the hspital, Memrial will pst and/r make available a plain language summary f the FAP. Psted materials will include instructins n hw t btain a printed versin f the plain language summary and the FAP applicatin free f charge. The FAP summary and applicatin will be available nline at Infrmatin n hw t apply fr FAP will be included n patient s statements. Printed cpies f the Financial Assistance Plicy and Applicatin may als be btained by: Calling Custmer Service at (574) Presenting t the Cashier s ffice lcated at: 615 N. Michigan St., Suth Bend, IN Request by mail in writing t: Memrial Hspital f Suth Bend Attn: Patient Accunts 615 N. Michigan St. Suth Bend, IN Patients with balances after insurance (e.g. deductibles, c-pays, and c-insurance amunts) may be eligible fr FAP if the eligibility requirements are met. Patients wh have exhausted plicy limits are eligible fr FAP if the eligibility requirements are met. (The remaining accunt balances after the plicy limits are exhausted are cnsidered uninsured and are eligible fr the FAP) Medicare patients are eligible fr FAP if the eligibility requirements are met. Patient must c-perate in supplying all third-party insurance infrmatin and third-party liability infrmatin. The patient must exhaust insurance/third-party liability cverage prir t patient receiving financial assistance thrugh FAP. The patient must cperate with pursuing enrllment in all affrdable health cverage prgrams that are accessible t them prir t cnsideratin f financial assistance apprval. Assistance with the assessment and enrllment is prvided as a service f the hspital free f charge t the patient by certified Indiana Navigatrs and Certified Applicatin Cunselrs. If the accunt is with a cllectin agency, the patient may still apply fr FAP as lng as the date f service is within 2 years f the applicatin date. Applicatin fr Assistance The patient's eligibility fr FAP will be determined thrugh an applicatin prcess. The Memrial Hspital f Suth Bend Financial Assistance Applicatin frm is the valid applicatin frm fr the applicatin prcess. Memrial Hspital f Suth Bend s Financial Assistance Plicy and applicatin will be made available t all patients. A signature is required n the applicatin (the patient, guarantr r legal representative). It is the respnsibility f the patient/guarantr t cmplete an assistance applicatin. The applicatin requires the patient t prvide their name, current address and valid cntact infrmatin and the names and ages f persns in their husehld. The applicatin requires the patient t list all incme amunts and their surces.

4 Page 4 f 10 Dcumentatin f all infrmatin prvided n the applicatin is required t cmplete the assistance applicatin. Memrial Hspital f Suth Bend, r its designee, may use natinal databases frm credit bureaus t verify r validate the infrmatin that is prvided. A written statement frm the individual(s) that are supprting the applicant may als be requested if current incme r lack theref is nt sufficient t meet their daily living expenses. Patient advcates are available t help anyne wanting t apply fr assistance and are available during business hurs at the hspital and Patient Financial Services ffice. Verificatin f requested incme and a cmplete list f all cuntable husehld members may be required. A FAP applicatin may be used fr cvered services that are prvided up t 6 mnths after the date the FAP applicatin was apprved. The patient may appeal the decisin f denied financial assistance by writing: Executive Directr f Revenue Cycle 615 N. Michigan St, Suth Bend, IN Charges Memrial Hspital f Suth Bend will nt charge patients apprved fr financial assistance under this FAP fr emergency r ther medically necessary care mre than the amunts generally billed t individuals wh have insurance (i.e., Memrial Hspital f Suth Bend will nt charge patients apprved fr Financial Assistance under this Plicy fr emergency r ther medically necessary care mre than the Grss Charges fr such care multiplied by the AGB Percentage. Refer t AGB percentage in Attachment 1. Financial Assistance Criteria The plicy set frth allws fr patients t qualify fr assistance by tw means: financial r catastrphic. The Financial Assistance Prgram als allws fr partial assistance r full assistance based n eligibility criteria set frth in this plicy. Financial Assistance A patient qualifying fr financial assistance is a persn wh is uninsured r underinsured, receives medically necessary care and unable t pay their bill. T be eligible fr assistance under the financial assistance guidelines, a persn's incme shall be at r belw a percentage f the Federal Pverty Level (FPL) as determined by Federal Pverty Guidelines. (See Attachment 1 fr a table f apprval percentages based n % f FPL). Husehld size and incme determines the % f FPL. Memrial Hspital f Suth Bend, r its designee, may cnsider ther financial assets and liabilities f the persn when determining eligibility. Memrial Hspital f Suth Bend will use the mst current pverty incme guidelines issued by the U.S. Department f Health and Human Services t determine an individual's eligibility fr financial assistance. The pverty incme guidelines are published annually in the Federal Register and fr the purpses f this plicy will becme effective the first day f the mnth fllwing the mnth f publicatin. T qualify under the Financial Assistance prtin f this plicy, a cmpleted, signed Financial Assistance applicatin must be submitted and prf f incme, prf f n incme, prf f lack f financial assets and ther required dcuments must accmpany the applicatin. Catastrphic Assistance Criteria A patient qualifying fr catastrphic assistance is a persn whse hspital bills exceed a specified percentage f the persn's annual grss incme as set frth in this plicy and wh is unable t pay the remaining bill. T be eligible fr catastrphic assistance the amunt wed by the patient must exceed ne hundred fifty (150) percent f the patient's annual grss incme and the patient must be unable t pay the remaining bill. Memrial Hspital f Suth Bend may cnsider ther financial assets and liabilities f the persn when determining ability t pay. If a patient has cash assets, thse assets will be added t their incme when determining eligibility fr assistance. If a determinatin is made that a patient has the ability t pay the remainder f the bill, such a determinatin des nt prevent a reassessment f the patient's ability t pay at a later date shuld their financial circumstances change.

5 Page 5 f 10 After eligibility is determined under this prvisin, assistance will be prvided t discunt the bill by 75% f the current balance. Factrs t be cnsidered fr Financial Assistance Husehld Size and Incme The fllwing factrs may be cnsidered in determining the eligibility f the patient fr assistance and must be prvided by all incme earning residents in the cuntable husehld unit unless they are nt dependents based n IRS guidelines fr determining whether a husehld member can be cnsidered a dependent. Indiana wrkfrce wage reprt fr last 2 quarters (unemplyment incme) Last 3 pay stubs r a letter r printut frm emplyer(s) prviding verificatin f grss incme if currently emplyed. This dcumentatin shuld nt be mre than 30 days ld frm date f issue and include year-t-date infrmatin. Last 3 bank statements (including explanatins f regular depsits nt explained by pay stubs) Scial Security award r entitlement letter r ther prf f grss mnthly award. Retirement incme. Investment incme. Statement frm persn(s) that are prviding direct supprt Number f dependents. Mst recent tax return (including W2 and all supprting schedules) Other financial bligatins. The amunt and frequency f hspital/medical bills. Other financial resurces that prduce incme. If Self-Emplyed, Grss Incme less Cst f Gds sld and emplyee salaries Financial Capacity Individuals with the financial capacity t purchase health insurance cverage thrugh the Health Insurance Marketplace may be required t purchase and will be prvided access t meet with an Indiana Certified Navigatr as a means f assuring access t healthcare services, fr their verall persnal health, and fr the prtectin f their individual assets. Individuals wh have been fund t be ineligible fr Medicaid r ther affrdable health care cverage must prvide prf f denial. Fd Stamps r Supplemental Nutritin Assistance Prgram (SNAP) will nt be cunted as incme. Csmetic Services are nt eligible fr any type f assistance and cannt be included in the amunt f hspital/medical bills wed. Reasns fr nt being eligible fr FAP Husehld incme exceeds the maximum f the FPL. Hwever, the patient may be eligible fr an adjustment f charges discunt r catastrphic discunt. If a patient is eligible fr Medicaid, the Health Insurance Marketplace, (Healthcare.gv) r ther state r federal prgrams and the patient fails t cperate in the applicatin, re-applicatin, r appeal prcess, r the patient des nt pay the required mnthly premium, thereby making the patient ineligible fr the State prgram. If the patient is eligible and enrlled in a Healthcare Marketplace plan and des nt pay the required mnthly premium, thereby causing the health plan t discntinue cverage. Patient is in the custdy f a unit f Gvernment, which is respnsible fr cverage f the medical needs f the patient. Services are nt medically necessary r excluded frm the prgram. Excluded services include, but are nt limited t: Csmetic surgery Infertility treatments, fertility services, birth cntrl, sterilizatin, reversal f sterilizatin;

6 Page 6 f 10 Services denied by yur insurance due t nn-cmpliance with yur insurance cverage requirements; Services deemed nt medically necessary; Services reimbursed directly t yu by yur insurance cmpany; Services reimbursed by anther third party Services required fr emplyment, schls, r athletics Presumptive Eligibility A patient in any f the fllwing circumstances will be autmatically deemed eligible fr financial r ecnmic assistance (presumptively eligible). N assistance applicatin is necessary if patient is deemed presumptively eligible fr assistance. Dcumentatin validating these circumstances may be required. Patient and/r respnsible party reside at Salvatin Army, Center fr the Hmeless, Hpe Rescue Missin, r any similar hmeless shelter r they are hmeless and are ineligible fr Medicaid r ther health cverage prgrams. Patient is deceased and n estate has been filed. Patient is enrlled in a limited benefit Medicaid prgram (i.e. Emergency Only, Family Planning, etc) and the current service is nt cvered by their Medicaid plan. There must be a denial f cverage frm Medicaid prir t the balance being adjusted t charity. Failure t Prvide Apprpriate Infrmatin Failure t prvide infrmatin necessary t cmplete a financial assessment may result in a negative determinatin, but the accunt must be recnsidered upn receipt f the required infrmatin. The accunt may als be submitted fr apprval if Memrial Hspital f Suth Bend has been able t verify infrmatin frm a reliable third party, i.e. Scial Security, Medicaid, credit reprting bureau, etc. A determinatin f eligibility fr financial r catastrphic assistance may be made withut a cmpleted assessment frm if the patient r infrmatin is nt reasnably available and eligibility is warranted under the circumstances. This will be apprved at the discretin f the Executive Directr f Revenue Cycle. Patients wh fail t prvide required dcumentatin r infrmatin will be prvided ntificatin. N patient may be denied assistance due t their failure t prvide infrmatin r dcumentatin nt specified in the FAP r applicatin. Financial Assistance Determinatins All cmplete applicatins will receive a determinatin fr the award f financial assistance. The patient will be prvided with a written cpy f the final determinatin. Favrable Determinatins A favrable determinatin will include the fllwing infrmatin: The date f apprval Percentage f apprved assistance Length f time that apprval is applicable Unfavrable Determinatin An unfavrable determinatin will include a reasn: Services are categrically excluded frm cnsideratin (i.e. nn-emergent r csmetic) The individual is fully cvered, r receives services fully cvered by a third-party insurer r gvernment prgram The eligibility standards under FPL were nt met The individual did nt take reasnable actin t btain third-party cverage they were determined t be eligible fr. They have received payment frm a third-party fr services The individual has nt cmplied with requests frm third-party payer

7 Page 7 f 10 Credit and Cllectins Practices Memrial Hspital f Suth Bend relies n timely payment f patient accunts receivable t allw the Hspital t cntinue t prvide high-quality medical care and t secure the latest in health care technlgy fr its patients. Memrial Hspital, recgnizing the burden that unexpected health care expenses can place n patients and their families, will assist patients t reslve pen accunts fr hspital services by wrking with third party payers t adjudicate patient s insurance claims and by prviding alternative payment plans fr patients. With the exceptin f sme Gvernment and cntracted care plans, ultimate respnsibility fr reslutin r payment f accunts rests with the patient. Patients are expected t wrk with Hspital persnnel t reslve accunts with their insurance cmpanies and/r emplyers as apprpriate. Where there is an estimated self pay balance due, Memrial Hspital will ask nn-emergency patients t pay that balance prir t r at the time f admissin/registratin. Uninsured patients will be screened fr ther cverage thrugh state assistance prgrams and/r financial assistance eligibility prir t requesting a depsit fr care. Memrial Hspital f Suth Bend may request and cllect a depsit, based n the patient s ttal estimated prtin f a bill, frm apprpriate nn-emergency inpatient admissins, same day surgery patients, and patients scheduled fr high-dllar utpatient prcedures prir t r at the time f admissin r registratin. In the event that a request fr payment is nt made prir t r at the time f the patient s arrival, a Financial Cunselr may calculate the estimated depsit amunt and cnfer with the patient/guarantr fr payment fllwing the admissin r registratin prcess via a financial interview. (In sme instances, this culd ccur while the patient is in his/her assigned rm.) At the time f discharge, Emergency patients may be requested t pay any c-pay r deductible. Where apprpriate, Memrial Hspital f Suth Bend may identify and request payment f, aged patient balances as part f the request fr depsit. Payment fr pen prir balances will nt delay emergency r medically necessary care. Aged pen prir balances will be cnsidered by the Cllectin Staff in Patient Accunt Services whenever payment arrangements r an alternative payment prgram is develped fr a patient. Uninsured patients are given a 35% discunt frm grss charges. Memrial Hspital f Suth Bend will cnduct financial interviews with patients and/r guarantrs when necessary. All financial interviews will be cnducted in an envirnment that is bth private and prfessinal. In additin t cash, check, and credit cards, the apprved payment arrangement methds might include: Hspital Payment Plan A payment plan directly with the hspital is nt t exceed three mnths. Exceptins must be apprved by the Directr r Manager f Patient Accunt Services r Executive Directr f Revenue Cycle. Patients may be required t sign a prmissry nte based n the agreed upn payment arrangement. CarePayment An extended payment plan which allws the patient an extended perid nt t exceed 36 mnths at 0% interest t pay their balance between $100 and $15,000. Patients may be autmatically enrlled in the CarePayment plan if their accunt has nt been paid in full 2 mnths after their first statement. All patients are eligible prvided that they prvide a valid scial security number, are nt n a gvernment watch list, are ver 18 and have nt previusly defaulted n their CarePayment accunt. Medicaid/ HIP Patients wh d nt have cverage when they present t the hspital fr treatment will be screened fr ther cverage thrugh state assistance prgrams. An Eligibility Specialist will assist the patient/guarantr t cmplete and submit all necessary frms required by the Indiana Department f Public Aid fr these types f prgrams. Hspital Financial Assistance Reasnable effrts will be made t determine if patients are eligible fr Financial Assistance thrugh the hspital Financial Assistance Prgram. If a patient des nt qualify fr financial assistance and des nt pay their accunt accrding t the ptins prvided r fails t pay their balance after applying qualified financial assistance,

8 Page 8 f 10 then the patient s accunt will be prcessed fr placement with a cllectin agency accrding t the Bad Debt Write Off plicy. Patients will be issued a Final Ntice 30 days prir t placing accunts with a cllectin agency and pursuing any extrardinary cllectin actins. Extrardinary cllectin actins will nt be taken until after Memrial Hspital has made reasnable effrts t determine if a patient will qualify fr financial assistance. Extrardinary cllectin actins may include suit, wage garnishment, lien r adverse credit bureau reprting Failure f Patient t pay Remainder f Accunt after Financial Assistance Failure f a patient/guarantr t pay the remainder f their accunt after deducting the assistance prtin may cause the accunt t be placed with a cllectin agency. Patients will be issued a Final Ntice 30 days prir t placing accunts with a cllectin agency. The remainder f the accunt will be subject t any cllectin actin including legal recurse such as suit, wage garnishment, lien r adverse credit bureau reprting if it remains unpaid. Prcessing and Apprvals Once a patient s financial assistance applicatin has been prcessed, a request will be sent fr apprval. Apprvals are required based n the belw amunts: Up t $4,000 Cllectin Supervisr Up t $10,000 Patient Accunts Manager Up t $25,000 Patient Accunting Directr Up t $50,000 Executive Directr f Revenue Cycle Unlimited (required ver $50,000) Chief Financial Officer Financial Assistance will apply retractively t all pen accunts with dates f service that are within 2 years f the apprval date. Dcument Revisin Histry: Review Date: Revised Date: Reviewed/Revised By: Summary f Changes: 11/22/ /22/2015 Julie Phillips Updated t new plicy frmat. Expanded definitins fr apprval criteria. Changed apprval level fr Crdinatr t align plicies with bth hspitals in the system. Added definitin fr Catastrphic Assistance. Added list f nn-cvered prviders. Updated language surrunding calculatin f AGB. Added limit fr lkback timeframe fr accunt apprvals. 11/30/2017 1/7/2018 Julie Phillips Added billing and cllectins practices int Financial Assistance Plicy. Updated apprval levels t add level fr Executive Directr. Updated Office address fr Billing Office SIGNATURES OF APPROVAL: Date Signed Signature Name Title

9 Page 9 f 10 Attachment 1 Discunt Schedule Percentage f Federal Pverty Level (FPL) Reductin Percentage 0% t 200% 100% 201% t 300% 75% 301% t 350% 62% (AGB percentage*) *AGB percentage updated 2/26/18

10 Page 10 f 10 Attachment 2 Prviders Nt Cvered by Financial Assistance Plicy Beacn Medical Grup Physicians Memrial Hspitalist Grup Suth Bend Clinic Physicians Radilgy, Inc ObGyn Assciates f Nrthern Indiana Michiana Anesthesia care Allied Physicians Ascendant Orthpedic Alliance Michiana Hematlgy/Onclgy Pediatrix, Inc Suth Bend Medical Fundatin MRI Center Nephrlgy Physicians, LLC Otrhinlarynglgy Assciates Oaklawn Psychiatric Center Campbell Ear, Nse and Thrat Urlgy Assciates f Suth Bend General and Vascular Surgery Urlgy Assciates f Suth Bend Pediatric Cardilgy f Michiana Midwest Eye Cnsultants Michiana Gastrenterlgy Family Medicine f Suth Bend Bendix Family Physicians Michiana Family Medicine River Park Family Medicine