Policy & Procedure X Corporate X SLCH X GSRMC X SNLH X SAGH X SPCH Page 1 of 5 Revision #: 4 Owner: Finance Authorized by: SHS Board of Directors APPLICATION All SHS entities (includes Good Samaritan Regional Medical Center, Samaritan Albany General Hospital, Samaritan Lebanon Community Hospital, Samaritan North Lincoln Hospital, Samaritan Pacific Communities Hospital and SHS Medical Group). POLICY In keeping with the nonprofit, charitable mission of Samaritan Health Services (SHS) financial assistance will be provided to uninsured and insured patients with demonstrated and verified financial need. Medical care will be provided to individuals presenting with emergency medical conditions, without discrimination, regardless of their ability to pay for those services or their eligibility for financial assistance. PROCEDURE DEFINITIONS: 1. refers to a program through which medically necessary services are provided by SHS at a reduced cost or without charge when it has been determined that payment for those services cannot be obtained through insurance, outside agencies or private means. 2. Medical Necessity refers to care that, in accordance with clinically accepted parameters, is reasonably necessary to: a. Prevent the onset or worsening of an illness, condition, or disability; b. Establish a diagnosis; c. Provide palliative, curative or restorative treatment for physical, behavioral and/or mental health conditions; and/or d. Assist the individual to achieve or maintain functional capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age. Each service is performed in accordance with national standards of medical practice generally accepted at the time the services are rendered and must be sufficient in amount, duration, and scope to reasonably achieve its purpose. Course of treatment may include observation only or, when appropriate, no treatment at all. There are certain service exclusions that are not typically eligible for financial assistance, including, but not limited to cosmetic services, bariatric procedures and other services not generally deemed medically necessary. 3. Income refers to total cash receipts before taxes derived from wages and salaries, welfare payments, Social Security payments, strike benefits, unemployment or disability benefits, child support, alimony and gross earnings from business and investment activities paid to members of the household. 4. Family (Census Bureau definition): A group of two or more people who reside together and who are related by birth, marriage, or adoption. According to Internal Revenue Service rules, if the patient claims someone as a dependent on their income tax return they may be considered a dependent for purposes of the provision of financial assistance.
Page 2 of 5 5. Amount Generally Billed (AGB) refers to the average amount accepted as payment in full for the combination of Medicare and commercially insured patients. AGB is calculated annually using a look-back method for the previous 12 months and includes claims for all patients covered by traditional Medicare, Medicare replacement (or Medicare Managed Care), and all commercial health plans. The AGB percentage is calculated by taking the sum of claims paid in full (including insurance payments and patient coinsurance, copayments and deductibles) divided by the associated gross charges for those claims. AGB may be different among SHS facilities as the percentages of patients that are Medicare and/or commercially insured varies by location. 6. Extraordinary Collection Actions (ECA) refers to the following actions: Placing a lien on property, attaching bank accounts, filing civil action under contract law, garnishing wages, reporting to a credit agency/bureau. SHS or its contracted collection agencies may take the listed actions for unpaid accounts subject to any courtrequired approvals. 7. Uninsured Patients are defined as persons who are uninsured or do not otherwise qualify for any governmental or private program that provides coverage for any of the services rendered. IMPLEMENTATION: 1. Signage and brochures informing patients of Samaritan Health s are available at appropriate access areas, including registration, and are also available on the internet (www.samhealth.org). 2. information is provided at least annually to community agencies such as local health departments, Medicaid offices, social service agencies, and physician practices. 3. Patients may apply for before, during, or after treatment, or at any time during the billing process and up to 240 days after the first billing statement was sent. 4. Emergent care is never delayed by an assistance determination or by requests for financial or other information regarding ability to pay. 5. is secondary to all other financial resources available to the patient, including, but not limited to: insurance, third party liability payers, government programs, outside agency programs, Health Saving Accounts balance and personal resources. 6. is not granted to patients that do not cooperate with efforts to determine eligibility for government or other insurance programs. 7. is granted only for medically necessary evidenced-based care. Services that are cosmetic or elective in nature or have been shown to lack clinical efficacy are not eligible for coverage under this policy. 8. Providers, not employed by Samaritan Health Services, that may provide care to a patient within a SHS facility, may or may not accept the SHS financial assistance determination. A list of these providers is available on the SHS website, at www.samhealth.org. FINANCIAL ASSISTANCE ELIGIBILITY 1. Anyone seeking may request a application. 2. applications are available by request at all Registration areas, by contacting Customer Service, or by downloading an application from the website (www.samhealth.org). 3. While a financial assistance application is pending review, SHS does not initiate collection efforts provided that the responsible party is cooperative with efforts to obtain payment from other sources. 4. screening requests may be proposed by sources other than the patient, such as the patient s physician, family members, community or religious groups, social services, or hospital personnel. 5. In addition to a credit application, a patient applying for financial assistance allowance must provide proof of annual income, which may consist of:
Page 3 of 5 a. The most recently filed federal income tax return, when appropriate. b. Copies of past pay stubs for the past 3 months. c. Written verification of income from employer. d. Statements from Social Security Administration. e. Other documents deemed necessary by the patient representative. 6. Annual income consists of: a. Wages earned by members of the household during the past year and/or possible future wages. b. Income from interest and dividends. c. Self-employment income. d. Child support or alimony which may require a copy of court record. e. Unemployment benefits. f. Workers compensation. g. Life insurance proceeds. h. Pension or profit-sharing payments. i. Social Security payments. j. Other income. 7. Any and all possible sources of payment must be considered before a financial assistance allowance is granted, and will include: a. Any insurance coverage the patient may have. b. Any third-party coverage, i.e., crime victims. c. Application to Oregon Health Plan, Senior or Disabled Services, or other state/federal programs. 8. The patient and spouse must submit all required documentation and sign the credit application before being considered for financial assistance. Failure to submit all reasonable requested documentation in the time frames stated will result in an automatic denial of the application. 9. A credit check may be requested by SHS. 10. The financial assistance allowance is determined using an income table based on the Federal Poverty Guidelines. The table is updated annually and includes determinants of income and family size and is based on the federal poverty level. (Poverty guidelines are available in the Regional Business Office.) Federal Poverty Percentages Adjustment Uninsured Patient Insured Patient 0 to 225% 100% 100% 226 to 300% 50% 0% 11. Patients that qualify under the financial assistance program are not charged more than the AGB for services that are eligible for financial assistance. 12. A letter will be sent to the patient/guarantor after the financial assistance allowance has been approved. 13. A denial letter will be sent if the patient does not qualify for financial assistance allowance. 14. The patient/guarantor may reapply within 30 days for consideration or further reduction. If a patient is seeking assistance with medical bills but does not meet income qualifications for financial assistance under the guidelines of the scale, he/she may request a review for a discount based upon catastrophic consideration. If the patient s balance exceeds 20% of a patient s annual income, he/she may be eligible for catastrophic financial assistance. Catastrophic approvals require Vice President approval.
Page 4 of 5 Collection Practices: 1. SHS will send a minimum of three (3) statements to the patient, which informs the patient of the amount due and of the patient s opportunity to complete a Application. SHS may make an attempt to contact the patient by telephone at the number provided by the patient (if any) to inform the patient of the amount due and of the patient s opportunity to complete a Application, and stating that completion of such application may afford the patient free or reduced cost care. 2. If there is a balance owing after financial assistance determination and the patient does not comply with agreed-upon payment arrangements, SHS will make two attempts to provide the patient with notice by mail. If the patient s financial situation has changed, the patient will be given an opportunity to work out new payment arrangements. 3. If the patient does not make payment arrangements, or if the patient fails to comply with any payment arrangements made, SHS may refer the outstanding account balance to a collection agency. 4. SHS and/or its collection agencies may engage in routine collection practices including but not limited to reporting to credit bureaus, filing voluntary liens, garnishing wages, and taking legal action to collect balances owing. 5. SHS and/or its collection agency may place liens on real property following final judgment in a lawsuit brought to collect the account balance. Absent special circumstances, SHS will instruct its collection agencies not to foreclose on liens on primary residences until the residence is sold or the patient and his/her spouse have died or otherwise vacated the residence. 6. Presumptive Determination- SHS understands that certain patients may be unable to complete a financial assistance application, comply with requests for documentation, or are otherwise nonresponsive to the application process. As a result, there may be circumstances under which a patient s qualification for financial assistance is established without completing the formal assistance application. Under these circumstances, SHS may utilize other sources of information to make an individual assessment of financial need. This information will enable SHS to make an informed decision on the financial need of non- responsive patients utilizing the best estimates available in the absence of information provided directly by the patient. SHS may utilize a third-party to conduct an electronic review of patient information to assess financial need. The electronic technology will be deployed prior to bad debt assignment after all other eligibility and payment sources have been exhausted. This allows SHS to screen all patients for financial assistance prior to pursuing any extraordinary collection actions. The data returned from this electronic eligibility review will constitute adequate documentation of financial need under this policy. When electronic enrollment is used as the basis for presumptive eligibility, the highest discount of full free care will be granted for eligible services for retrospective dates of service only. If a patient does not qualify under the electronic enrollment process, the patient may still be considered under the traditional financial assistance application process. Patient accounts granted presumptive eligibility will be reclassified under the financial assistance policy. They will not be sent to collection, will not be subject to further collection actions, will not be notified of their qualification and will not be included in the hospital s bad debt expense. Communication of the Program to Patients and Within the Community. Notification about financial assistance available from SHS, which shall include a contact number (800-640-6339), and information shall be disseminated by SHS by various means, which will include, but are not limited to:
Page 5 of 5 1. Patients registered in the Emergency Department or Admitting Office will receive a notice advising the patient that the hospital offers discount, financial assistance, and other payment alternative programs; 2. Outpatient Registration will provide the same notice to all patients who have not previously been treated at SHS; 3. By posting notices in various areas including the emergency room, billing office, and outpatient registration areas; and 4. At other public places as SHS may elect. SHS also shall publish and widely publicize a summary of this financial assistance policy on facility websites, in brochures available in patient access sites and at other places within the community served by the hospital as SHS may elect. Such notices and summary information shall be provided in the primary languages spoken by the population serviced by SHS. REFERENCES Section 501(r) of the Internal Revenue Code REVIEW/REVISION HISTORY Date of Revision Revision # Revision / Review Revision Description Date Released 0 New 12/22/2015 0-1 Revision Archived 12/22/2015 2 Revision Updated to include the presumptive eligibility language Collaborated With (i.e. Standardization Committee, VP s, Quality, Risk) Finance 6/21/2016 3 Revision Removed asset consideration language Finance 11/7/2016 4 Revision Updated AGB calculation language. Specify locations applicable for public posting. Minor formatting. Finance