Novant Medical Group Physicians Practices

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Lewis Cross
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1 TITLE Financial Assistance Policy NUMBER NMG-PC-CC-701 July 09 JCAHO FUNCTIONS APPLIES TO Continuum Of Care Novant Medical Group Physicians Practices I. SCOPE / PURPOSE / POLICY STATEMENT Novant Health is committed to providing the best medical services to our community. In keeping with its charitable mission, it is the policy of Novant Health to provide needed medical care to citizens of the community, regardless of the patient s ability to pay. After verifying that the patient is not eligible for other public assistance programs (such as Federal or State healthcare coverage, i.e., Medicaid, SCHIP, etc.), Novant Medical Group, will apply discounts and/or Financial Assistance care based on the following: All Uninsured NMG Patients: patients whose annual family income falls below 300% of the current year s Federal Poverty Level Guidelines may be eligible for a 100% reduction of patient. Pharmacy items/prescriptions are excluded. (Exhibit 1). Patients whose annual family income is greater than 300% of current year Federal Poverty Level Guidelines are eligible to receive a 20% discount to their balance. The NMG Prompt Payment Policy may apply an additional 20% discount (total discount = 40%) to all charges if the balance for outpatient services is paid at the time of service. Patients who have insurance coverage are not eligible for this discount. Pharmacy items/prescriptions are excluded. A patient s eligibility may be determined prior to or after receiving services and is valid for up to six months before the patient is required to reapply. Patient accounts that meet financial assistance criteria but have account balances placed with a collection agency in the previous six-month period should be returned to the NMG CBO. All NMG Patients regardless of insurance status will be eligible for a Catastrophic Discount if their outstanding balance places an unreasonable hardship in relationship to their financial resources based on established criteria. Eligibility Criteria individuals considered for this program must meet all of the following criteria: A. The total NMG remaining account balance after insurance payments must be at least $5,000. B. The account has received the expected payment from the insurance company (if applicable). POLICY/PROCEDURE NMG Financial Assistance Page 1 of 7

2 C. The patient or responsible party does not have to be a State resident or U.S. citizen. D. The patient or responsible party will receive and must complete a written financial assistance application (see attachment) and provide all supporting data required to verify eligibility. E. The individual does not meet Financial Assistance requirements. F. Discounts will apply to only medically necessary services. Elective procedures or those not normally covered by insurance (plastic surgery, elective gastric bypass) will not be eligible for this assistance. G. Any account that has been submitted to bad debt for collection purposes will be reviewed on a case-by-case basis. H. The discounted amounts will be individualized based upon available financial resources. I. Potential outcomes will include full payment, full write-off, and/or partial write-off with agreed-upon payment plan. J. Failure by the patient or responsible party to meet the obligations of the contract within the agreed upon time frame will result in further collection action up to and including referral to a collection agency. This action recognizes that some patients have appropriate financial resources and that payment of their bills is an important obligation. System Requirements A. Upon approval, a discount will be applied manually to the patient s account utilizing a specific adjustment code. EXCLUSIONS: This policy only applies to services rendered at Novant Health facilities and does not apply to services rendered at non-novant-affiliated physician practices or by any independent physicians or practitioners. This policy also does not apply to services provided within or outside the hospital/facility by physicians or other healthcare providers including but not limited to Anesthesiologists, Radiologists, and/or Pathologists, who are not employed by Novant. This policy does not apply to elective procedures (including but not limited to cosmetic surgery). II. QUALIFIED PERSONNEL NMG Office Staff NMG CBO Staff III. EQUIPMENT POLICY/PROCEDURE NMG Financial Assistance Page 2 of 7

3 None IV. PROCEDURE The procedure serves as a guideline to assist personnel in accomplishing the goals of the policy. While following these procedural guidelines personnel are expected to exercise judgment within their scope of practice and/or job responsibilities. Patients with limited financial resources and who do not qualify for State Medical Assistance Programs may receive a discount on all services provided within a Novant Health physician practices. The amount of patient responsibility is determined by poverty guidelines set forth by the U.S. Department of Health and Human Services. The following procedure must be followed in order to obtain approval. Income Verification The total family gross income at the date of application will be used to determine the patient s eligibility for Financial Assistance care. Income may be verified using applicants and coapplicants last two paycheck stubs, last two bank statements, a letter from employer indicating pay, prior year W2 form, prior year 1040 form, or other means deemed appropriate by NMG. AFDC or SSI for children will not be included in the family s gross income. Applicants who have no income must provide a statement of means indicating how they are paying for basic necessities such as food, shelter, etc. Family Unit includes husband, wife, and any children (including stepchildren) that live in the home or are qualifying dependents for tax purposes. If the patient has not already applied for Medicaid coverage, the patient should be directed to do so. In order to qualify for a discount, the patient must have been denied Medicaid coverage. A copy of the Medicaid denial will be filed with the application. The patient must complete the Financial Assistance application (Exhibit 2) and return it with the required documentation to the Practice s Customer Service Navigator (CSN) for CBO practices or the Manager/Administrator for non-cbo practices. NMG CSNs/Practice Managers will be responsible for identifying eligible NMG patients for Financial Assistance. Based on the recommendation of the practice and meeting of eligibility requirements, NMG CBO Management will be responsible for approval of NMG financial assistance applicants. The NMG CSN/Practice Manager will review the application and supporting documentation and forward all to the NMG CBO Financial Assistance Care Supervisor. A copy of all documents should be filed at the practice. Final approval will be determined by the NMG CBO. Patients will be notified by a NMG CBO CSN/Practice Manager of their eligibility, the amount of the write-off and the remaining amount due. The patient is responsible for the full amount of the patient account balance remaining after the deduction is applied. It is the responsibility of the NMG CBO CSN is to enter the Financial Assistance Care into the practice management system with a coverage termination date of six months past the date of approval for CBO Practices. The NMG CSN will also notify the practice of the patient s approval. The practice manager is responsible for these activities for non-cbo practices. Patients who incur hospitalization charges by NMG Providers and subsequently do not present to the NMG practice for follow up care will be deemed indigent/homeless and automatically POLICY/PROCEDURE NMG Financial Assistance Page 3 of 7

4 qualify for Financial Assistance Care under all the following conditions. The patient is unable to be contacted by address, telephone, or skip tracing methods. It has been verified that the patient is not eligible or a current recipient of Medicaid. V. DOCUMENTATION VI. DEFINITIONS NMG Novant Medical Group CBO - Central Billing Office VII. RELATED DOCUMENTS Exhibit 1 Exhibit 2 VIII. REFERENCES IX. SUBMITTED BY Kelly Baker, Senior Director, NMG CBO X. KEY WORDS Financial, Assistance, CBO, Charitable XI. INITIAL EFFECTIVE DATE 07/01/09 DATES REVISED DATES REVIEWED POLICY/PROCEDURE NMG Financial Assistance Page 4 of 7

5 Exhibit Guidelines - Income as a % of Poverty Level Persons in Family or Household 48 Contiguous States and D.C. 300% (100% Discount) All Patients 1 $ 10,830 $ 32,490 2 $ 14,570 $ 43,710 3 $ 18,310 $ 54,930 4 $ 22,050 $ 66,150 5 $ 25,790 $ 77,370 6 $ 29,530 $ 88,590 7 $ 33,270 $ 99,810 8 $ 37,010 $ 111,030 For each additional person, add $ 3,740 $ 3,740 POLICY/PROCEDURE NMG Financial Assistance Page 5 of 7

6 Exhibit 2 Today s Date: Financial Assistance Application Do you have medical insurance including Medicare and/or Medicaid? If yes, name of insurance I. Patient Demographics Patient Name: (Last) (First) (Middle) (SSN) (DOB) Guarantor s Name: (Last) (First) (Middle) (SSN) (DOB) Address: (Street) (City) (State) (Zip Code) (Phone Number) II. Household Information Marital Status (Circle One): Married Single Separated Other How many people live in your home (including yourself, spouse and children)? List names & relationship on the back of this form. III. Employment/Income Are you employed? - Employer: - Occupation: Length of Employment: If married, is your spouse employed? Employer: Occupation: Length of Employment: Monthly Income Applicant Spouse Employment Social Security Unemployment Child Support/Alimony Other Act Number(s) Total Monthly Income I certify that the information provided is true and to the best of my knowledge. I understand that fraudulent or misleading information will make me ineligible for any financial assistance. I authorized the release of any information needed to verify the information provided and for billing and collections in compliance with applicable federal and state laws. Proof of income may be required before any consideration is made. Acceptable proof of income may be, but not limited to: copy of paycheck stubs, copy of last year s tax return, or letter from employer stating present salary and hours worked. Signature of Patient/Guarantor Date Office Use Only Signature of Interviewer Date Administrative Signature Date Approved Percentage Comments POLICY/PROCEDURE NMG Financial Assistance Page 6 of 7

7 PROCEDURE SIGNATURE SHEET (one copy only to be maintained by author) Company / Facility(s) Department Procedure Action Novant Health Novant Medical Group Financial Assistance Care Approved PROCEDURE APPROVED BY: Title Approved By Signature Date NMG Chief Operations Officer Michelle Grier 04/16/09 NMG CBO, Senior Director Kelly Baker 06/01/09 COMMITTEES APPROVED BY: Committee Chairperson/Designee Date NMG Practice Standards Committee John Card, MD, Chairman 07/02/09 DATES OF APPROVAL: Date Revised 07/2009 Date to be Reviewed 07/2012 POLICY/PROCEDURE NMG Financial Assistance Page 7 of 7

Financial Assistance Program Application

Financial Assistance Program Application Guidelines: 1. The hospital uses a sliding scale for Financial Assistance Program sponsorship based on annual income for all family members, residing in the same