Institute For Orthopaedic Surgery (IOS) Subject: Billing and Payments: General Guidelines

Transcription

1 Institute Fr Orthpaedic Surgery (IOS) Plicy and Prcedure Manual Subject: Billing and Payment: General Statements Purpse: T prvide directin t staff members in their interactin with patients and guarantrs T ensure the prtectin f the Facility s cash flw and cnsumer satisfactin T avid ptential bad debts by perating under a prudent and effective payment plicy T prvide educatin t patients and guarantrs as it relates t billing and cllectins f payment fr services rendered. T infrm the patient f deductibles, cpays, cinsurance amunts and ther patient respnsibility amunts T prvide a pathway fr cnsistency in billing and cllectins Payment n accunts will be pursued cnsistently, regardless f race, age, gender, ethnic backgrund, natinal rigin, citizenship, primary language, religin, educatin, emplyment r student status, dispsitin, relatinship, insurance cverage, cmmunity standing, r any ther discriminatry differentiating factr. IOS will nt engage in any extrardinary cllectin actins (as defined herein) against an individual t btain payment fr care befre reasnable effrts have been made t determine whether the individual is eligible fr assistance fr the care under its Healthcare Financial Assistance ( HFA ) Plicy. Scpe: Administrative Directr (AD) Chief Nursing fficer (CNO) Manager f Business Office Designated Staff Definitin: AGB Amunt generally billed fr medically necessary care t individuals wh have insurance cverage. Applicatin Perid The perid during which IOS must accept and prcess an applicatin fr financial assistance under its HFA plicy submitted by an individual in rder t have made reasnable effrts t determine whether the individual is eligible fr financial assistance under the plicy. The Applicatin Perid begins n the date the care is prvided and ends n the latter f the 240 th day after the date that the first pst-discharge billing statement fr the care is prvided r at least 30 days after IOS prvides the individual with a written ntice that sets a deadline after which ECAs may be initiated. ECAs ECAs are Extrardinary Cllectin Actins taken by IOS against an individual related t btaining payment f a bill fr care cvered under IOS s HFA plicy that require a legal r judicial prcess r invlve selling an individual s debt t party r reprting adverse infrmatin abut the individual t cnsumer credit reprting agencies r credit bureaus. HFA IOS s Healthcare Financial Assistance Plicy. HFA-Eligible Individual An individual eligible fr financial assistance under IOS s HFA plicy (withut regard t whether the individual has applied fr assistance under the HFA plicy). Plicy: Reviewed and Apprved By Hspital Administratin Crp. Resp. Plicy #: Page 1 f 6

2 Institute Fr Orthpaedic Surgery (IOS) Plicy and Prcedure Manual 1. It is the plicy f IOS that payment is due when services are rendered. As a service, IOS will submit fr patient any third party claims. 2. Any patient self-pay prtin is due within thirty (30) days f receipt f the service. [Fr purpses f definitin: self-pay prtin is defined as nn-cvered services, cpayments, and deductibles.] 3. Every guarantr will be given reasnable time and cmmunicatin t be aware f and understand their financial respnsibility. The guarantr will be held financially respnsible fr services actually prvided and adequately dcumented. 4. IOS representatives and/r its designee will widely publicize its HFA plicy by, amng ther things, prviding a cpy f the plain language summary f the plicyprir t the patient being discharged. 5. Understanding each guarantr s insurance cverage is the respnsibility f the guarantr. Any self-pay liability secndary t insurance cverage is defined by the guarantr s insurance cverage and benefit design. I O S relies n the explanatin f benefits and ther infrmatin frm the guarantr and the insurance carrier fr eligibility, adjudicatin f the claim, and patient respnsibility determinatins. 6. A statement f hspital services is sent t the patient/guarantr in incremental billing cycles. In cases when the patient has n insurance cverage, that is a self-pay patient, the statement is sent after services are rendered. In mst cases when patients have cverage thrugh an insurance carrier, the statements are sent after the services have been rendered, claim is submitted, and claim has been adjudicated by the insurance carrier. There are sme cases, fr example, when there is a stp in the adjudicatin f a claim due t the patient needing t prvide additinal infrmatin, where a statement will be sent t the patient and/r guarantr prir t claim prcessing. 7. IOS representatives and/r their designees may attempt t cntact the patient/guarantr (via telephne, mail, r ) during the statement billing cycle in rder t pursue cllectins. Cllectin effrts are dcumented n the patient s accunt. Prcedure: 1. IOS will submit claims t insurance cmpanies accrding t established guidelines. 2. Cmplete billing infrmatin must be presented at the time f registratin and/r admissin. 3. IOS reserves the right, where agreements with the payer are nt t the cntrary, t determine the length f time befre the accunt becmes the respnsibility f the patient and their guarantr due t the lack f timely payment frm the insurance cmpany. 4. At n time, unless agreed t with the insurance cmpany t the cntrary, will an anticipated insurance payment verride the patient s bligatin t pay the balance utstanding. 5. IOS will make its best effrt t ntify patients f the insurance benefits verified by the patient s insurance cmpany within three (3) wrking days f the hspital s receipt f the insurance benefits verificatin. 6. Patients and guarantrs may request an itemized bill by cntacting a representative f the Accunts Receivable Department. IOS des nt rutinely send an itemized bill t the patient. 7. The guarantr will receive a mnthly statement that prvides an accunt status and lists any activity ccurring since the last statement. 8. Every effrt will be made t assure that every patient accunt statement is accurate and easily Reviewed and Apprved By Hspital Administratin Crp. Resp. Plicy #: Page 2 f 6

3 Institute Fr Orthpaedic Surgery (IOS) Plicy and Prcedure Manual Statement Cycle: understd by lay persns. The statement cycle will be measured frm the first statement sent t the patient (date sent) and include the fllwing: Subsequent statements sent t the patient/guarantr in 30 day increments t derive at the statement prcess: 1 st Date f first billing 2 nd 30 Days pst 3 rd 60 Days pst 4 th 90 Days pst and ntice f submissin t Cllectin Agency if amunts left unpaid r HFA applicatin nt received 5 th 120 Days pst - Submissin t Cllectin Agency A secndary Cllectin Agency may be used, subject t the prvisins f this plicy Extrardinary Cllectin Actins (ECAs): It is the plicy f IOS nt t engage in ECAs against an individual t btain payment fr care befre making reasnable effrts t determine whether the individual is eligible fr assistance under its HFA plicy. ECAs include: Selling a patient s debt t anther party; Reprting adverse infrmatin abut the individual t cnsumer credit reprting agencies r credit bureaus; Actins requiring legal r judicial prcess, such as cmmencing a civil actin against an individual and placing a lien n an individual s prperty (althugh exceptins include filing a prf f claim in bankruptcy and hspital liens n persnal injury judgments/settlements) r garnishing f wages. IOS may pursue all available means in the cllectin f delinquent accunts including thse actins requiring a legal r judicial prcess. IOS must be ntified f and apprve f any legal actin being taken in the cllectin f delinquent accunts by any vendrs wrking n behalf f IOS. Effrts t Determine HFA Eligibility: IOS will allw patients t submit cmplete HFA applicatins during a 240 day Applicatin Perid (as described herein). IOS will nt engage in ECAs against the patient r guarantr withut making reasnable effrts t determine the patient s eligibility under the HFA plicy. Specifically: IOS will ntify individuals abut the HFA plicy as described herein befre initiating any ECAs t btain payment fr the care and refrain frm initiating such ECAs fr at least 120 days frm the first pst-discharge billing statement fr the Reviewed and Apprved By Hspital Administratin Crp. Resp. Plicy #: Page 3 f 6

4 Institute Fr Orthpaedic Surgery (IOS) Plicy and Prcedure Manual care. If IOS intends t pursue ECAs, the fllwing will ccur at least 30 days befre first initiating ne r mre ECAs: IOS will ntify the patient in writing that financial assistance is available fr eligible individuals, identifies the ECAs the facility (r ther authrized party) intends t initiate t btain payment fr the care, and states a deadline after which such ECAs may be initiated that is n earlier than 30 days after the date that the written ntice is prvided; The abve ntice will include a plain language summary f the HFA plicy; IOS will make a reasnable effrt t rally ntify the patient abut the HFA plicy and hw the individual may btain assistance with the applicatin prcess. If IOS aggregates an individual s utstanding bills fr multiple episdes f care befre initiating ne r mre ECAs t btain payment fr thse bills, it will refrain frm initiating the ECAs until 120 days after it prvided the first pstdischarge billing statement fr the mst recent episde f care included in the aggregatin. Prcessing HFA Applicatins: If an individual submits an incmplete HFA applicatin during the applicatin perid, IOS will: Suspend any ECAs t btain payment fr the care; and Prvide the individual with a written ntice that describes the additinal infrmatin and/r dcumentatin required under the HFA r HFA applicatin frm that must be submitted t cmplete the applicatin and that includes the IOS cntact infrmatin. If an individual submits a cmplete HFA applicatin during the applicatin perid, IOS will: Suspend any ECAs t btain payment fr the care; Make an eligibility determinatin as t whether the individual is HFA-eligible fr the care and ntify the individual in writing f the eligibility determinatin (including, if applicable, the assistance fr which the individual is eligible) and the basis fr this determinatin. If the individual is determined t be HFA-eligible fr the care, IOS will: Refund t the individual any amunt he r she paid fr the care (whether t IOS r any ther party t whm IOS has referred t sld the individual s debt fr the care) that exceeds the amunt he r she is determined t be persnally respnsible fr paying as an HFA-eligible individual, unless such excess amunt is less than $5 (r such ther amunt published in the Internal Reviewed and Apprved By Hspital Administratin Crp. Resp. Plicy #: Page 4 f 6

5 Institute Fr Orthpaedic Surgery (IOS) Plicy and Prcedure Manual Revenue Bulletin). Take all reasnably available measures t reverse any ECA (with the exceptin f a sale f debt) taken against the individual t btain payment fr the care. When n HFA applicatin is submitted, unless and until IOS receives a HFA applicatin during the Applicatin Perid, IOS may initiate ECAs t btain payment fr the care nce it has ntified the individual abut the HFA plicy as described herein. Miscellaneus Prvisins: Anti-Abuse Rule IOS will nt base its determinatin that an individual is nt HFAeligible n infrmatin that IOS has reasn t believe is unreliable r incrrect r n infrmatin btained frm the individual under duress r thrugh the use f cercive practices. Determining Medicaid Eligibility IOS will nt fail t have made reasnable effrts t determine whether an individual is HFA-eligible fr care if, upn receiving a cmplete HFA applicatin frm an individual wh IOS believes may qualify fr Medicaid, IOS pstpnes determining whether the individual is HFA-eligible fr the care until after the individual s Medicaid applicatin has been cmpleted and submitted and a determined as t the individual s Medicaid eligibility has been made. N Waiver f HFA Applicatin Obtaining a signed waiver frm an individual, such as a signed statement that the individual des nt wish t apply fr assistance under the HFA plicy r receive the ntificatins described herein, will nt itself cnstitute a determinatin that the individual is nt HFA-eligible. Final Authrity fr Determining HFA Eligibility Final authrity fr determining that IOS has made reasnable effrts t determine whether an individual is HFA-eligible and may therefre engage in ECAs against the individual rests with the IOS Business Office. Agreements with Other Parties If IOS sells r refers an individual s debt related t care t anther party, IOS will enter int a legally binding written agreement with the party that is reasnably designed t ensure that n ECAs are taken t btain payment fr the care until reasnable effrts have been made t determine whether the individual is HFA-eligible fr the care. Prviding Dcuments Electrnically IOS may prvide any written ntice r cmmunicatin described in this plicy electrnically (fr example, by ) t any individual wh indicates he r she prefers t receive the written ntice r cmmunicatin electrnically. Reviewed and Apprved By Hspital Administratin Crp. Resp. Plicy #: Page 5 f 6

6 Institute Fr Orthpaedic Surgery (IOS) Plicy and Prcedure Manual Crrespndence cncerning IOS HFA plicies shuld be sent t the fllwing: Institute fr Orthpaedic Surgery Attn: Billing Department 801 Medical Drive Lima, Ohi Questins cncerning IOS HFA plicies shuld be directed t: (567) Additinal infrmatin is available at: Billing & Financial Assistance Reviewed and Apprved By Hspital Administratin Crp. Resp. Plicy #: Page 6 f 6