Document Owner: Mary Ellen George Date Created: 08/27/2014 Approver(s): George, Mary Ellen Date Approved: 09/09/2014

Transcription

1 POLICY STATEMENT Approximately forty-five million Americans lack basic health care coverage. In addition to the large number of uninsured, the number of underinsured has increased over the last decade. Studies have shown a strong link between lack of adequate health insurance coverage to inadequate health care received by individuals. St. Joseph Mercy Oakland (SJMO) is committed to: Providing access to qualify healthcare services with compassion, dignity and respect for those we serve, particularly the poor and the underserved in our communities; a. Caring for all persons, regardless of their ability to pay for services; b. Assisting patients who cannot pay for part or all of the care they receive; and c. Balancing needed financial assistance for some patients with broader fiscal responsibilities in order to sustain viability and provide the quality and quantity of services for all who may need care in our community. SCOPE SJMO associates who assist patients with payment obligations through billing, collection and financial support. DEFINITIONS None POLICY A. Effective Communications a. SJMO will provide financial counseling to patients about their hospital bills and will make the availability of such counseling known. b. SJMO will respond promptly and courteously to patients questions about their bills and to requests for financial assistance. c. SJMO will strive to achieve a billing process that is clear, concise, correct and patient friendly. d. SJMO will make available for review by the public specific information in an understandable format about what they charge for services. B. Assisting Patients Who May Qualify for Coverage a. SJMO will make available to patients information on hospital-based financial support policies and external programs that provide coverage for services. b. SJMO will make affirmative efforts to help patients apply for public and private programs for which they may qualify and that may assist them in obtaining and paying for healthcare services. 2 Printed copies are for reference only. Please refer to the electronic copy for the latest version. PAGE 1 OF 9

2 c. SJMO will communicate this information to patients in a way that is easy to understand, culturally appropriate, and in the most prevalent languages used in their communities. d. SJMO will have understandable, written procedures to help patients determine if they qualify for public assistance programs or hospital-based assistance programs. e. SJMO will make its policies or summaries of programs available to appropriate community health and human services agencies and other organizations that assist people in need. C. Affordability of Care for Patients with Limited Means SJMO will establish and maintain a policy to address the financial needs of all patients regardless of race, creed, sex, age or payor. Eligibility for assistance will be determined on an individual basis using specific criteria and evaluated on an assessment of the patient s and/or family s need, financial resources and obligations. a. Services eligible for financial support i. All medically necessary services, including medical and support services provided by SJMO, will be eligible for financial support. ii. Trauma and emergency care services will be provided to all patients, regardless of the patient s ability to pay. Such care will continue until the patient s condition has been stabilized prior to any determination of payment arrangements. iii. The authority to approve Mercy Support eligibility is limited to the Financial Counseling staff, Manager and Director of the Patient Access Department and the Vice President of Financial Services. b. Services not eligible for financial support i. Cosmetic services and other elective procedures not medically necessary will not be eligible for financial support. ii. Services not provided or billed by SJMO (e.g. independent physician services, private duty nursing, ambulance transport, etc.) are not covered by this policy. iii. As provided in section II.B, SJMO will make affirmative efforts to help patients apply for public and private programs. SJMO may deny financial support to those individuals who do not cooperate in applying for programs that may pay for their healthcare services. iv. SJMO may exclude services that are covered by an insurance program at another provider location but are not covered at SJMO after efforts are made to educate the patient and provided that EMTALA obligations are satisfied. c. Residency requirements 2 Printed copies are for reference only. Please refer to the electronic copy for the latest version. PAGE 2 OF 9

3 i. SJMO will provide financial support to patients who qualify for the program and who reside within their service areas. The eligible zip codes that define the SJMO service area include: 48009, 48025, 48083, 48084, 48085, 48098, 48301, 48302, 48304, 48306, 48307, 48309, 48320, 48321, 48322, 48323, 48324, 48325, 48326, 48327, 48328, 48329, 48340, 48341, 48342, 48343, 48346, 48347, 48348, 48359, 48360, 48362, 48382, 48383, 48386, ii. Applicants must provide a valid driver s license or state ID as documentation that they live within the eligible service area. In the event that no valid driver s license or state ID is available, alternative documentation may be provided (such as a utility bill, signed current lease, etc). iii. SJMO will provide financial support visit specific to patients from outside their service area who qualify for the program and who present with an urgent, emergent or lifethreatening condition. iv. SJMO may provide financial support visit specific to patients identified as needing service by physician foreign mission programs conducted by active medical staff for which prior approval has been obtained. d. Available Health Insurance Benefits i. An employed applicant must provide proof (i.e. a letter from his/her employer) confirming that health insurance benefits are not available to the employee. If an employed applicant has the option of purchasing health insurance, the Financial Counselors will consider the additional costs of the purchased health care insurance to determine Mercy Support eligibility. e. Establishing Patient Income i. Information provided to the Financial Counselors by the patient and/or family should include household earned income, including monthly gross wages, salary and selfemployment income; unearned income including alimony, child support, retirement benefits, dividends, interest and income from any other source; number of dependents in household; number of dependents in household based on the Federal tax return; and other information to determine the patient s financial status, including assets and liabilities. ii. An applicant s family or household size (eligible dependents) is established according to the criteria of the Michigan Family Independence Agency. Income from significant others and life partners living in the same residence may be considered if it used to provide household support. iii. Allowable expenses include: Medical expenses that are the responsibility of the patient (including durable medical equipment and prescriptions), court ordered child 2 Printed copies are for reference only. Please refer to the electronic copy for the latest version. PAGE 3 OF 9

4 care, court ordered monthly child support payments if the child is not considered as a dependent (member of the applicant household). iv. Applicant household income, allowable expenses, and assets will be used to determine adjusted monthly income using the following formula: Monthly gross income Monthly allowable expenses + Excess assets = Adjusted Monthly Income f. Documentation for Establishing Income i. Supporting documents such as payroll stubs, tax returns, credit history may be requested to support information reported and shall be maintained with the completed assessment. ii. Presumptive Charity SJMO recognizes that not all patients are able to provide complete financial application or provide requisite documentation. Therefore, approval for financial support may be determined based on available information. Examples of presumptive cases include deceased patients with no known estate, homeless patients, bankruptcies and members of religious organizations who have taken a vow of poverty and have no resources individually or through the religious order. For patients who are non-responsive to the application process, other sources of information may be used to make an individual assessment of financial need. For the purpose of helping financially needy patients with no insurance coverage, a thirdparty may be utilized to conduct a review of patient information to assess financial need. This review utilizes a healthcare industry-recognized, predictive model that is based on public record databases. Patient accounts granted presumptive charity status will be adjusted according to the policy. The discount granted will be classified as financial assistance; it will not be sent to collection. g. Consideration for Patient Assets i. A threshold level of assets has been established above which the excess assets will be utilized for payment of medical expenses. Protected assets include: 1. Equity in primary residence up to $100, Two vehicles per family unit 3. Business use vehicles 4. Tools or equipment used for business 5. Personal use property (clothing, household items, furniture) 6. IRAs, 401K, 403B, cash value retirement plans 7. Financial awards received from non-medical catastrophic emergencies 8. Irrevocable trusts for burial purposes 9. Federal/State administered college savings plans 2 Printed copies are for reference only. Please refer to the electronic copy for the latest version. PAGE 4 OF 9

5 ii. All other assets will be considered available for payment of healthcare expenditures. SJMO will count the excess available assets as current year income in establishing the level of discount to be offered to the patient. A minimum, $5,000 of available assets will be protected. Assets include: 1. Checking and savings accounts, 2. Certificates of deposit, 3. Stocks and bonds, 4. Secondary rental property or house, 5. Recreational vehicles, 6. Cash value life insurance, 7. Non-productive tools/equipment, 8. Motor vehicles (the equity only), 9. Pending lawsuits. h. Timeline for Establishing Financial Eligibility i. Every effort will be made by SJMO to determine a patient s eligibility prior to or at the time of admission or service. Financial assistance applications will be accepted until one year after the first billing statement but not more than six months after bad debt placement. ii. Determination for financial support will be made after all efforts to qualify the patient for governmental financial assistance or other programs have been exhausted. iii. SJMO will make every effort to make a financial support determination in a timely fashion. If other avenues of financial support are being pursued, SJMO will communicate with the patient regarding the process and expected timeline for determination and shall not attempt collection efforts while such determination is being made. iv. Once qualification for financial support has been determined, subsequent reviews for continued eligibility for subsequent services should be made every 6 months from the date of initial contact with the Financial Counseling Office. i. Level of Financial Support Federal Poverty Level of Level Support 0 200% 100% of charges % 64% of charges 2 Printed copies are for reference only. Please refer to the electronic copy for the latest version. PAGE 5 OF 9

6 i. Medical Indigent Support: Financial Support is also provided for Medical Indigent patients. Medical Indigence is defined as medical bills exceeding 20% of household income and assets. Medical Indigence will be evaluated on a case by case basis and will include a review of the patient s income, expenses and assets. Discounted rates shall not be greater than 64%. ii. While financial support should be made in accordance with the written criteria established, it is recognized that occasionally there will be a need for granting additional support to patients based upon individual considerations. Approval must be granted by the Director of Patient Access. j. Accounting and Reporting for Financial Support i. In accordance with the Generally Accepted Accounting Principles, financial support provided by SJMO is recorded in the financial statements at full charges in the category Charity Care. For the purposes of Community Benefit Ministry reporting, charity care is reported at estimated cost associated with the provision of Charity Care services. ii. Financial support must be systematically accounted for so that this component of community benefits for SJMO is accurately recorded. iii. The following guidelines are provided for the financial statement recording for financial support: 1. Financial support provided to patients under the provisions of Billing and Collection and Support for Patients with s, including the adjustment for amounts generally accepted as payment for patients with insurance, will be recorded under Charity Care Allowance. 2. Write-off of charges for patients who have not qualified for financial support under this policy and who are unwilling to pay will be recorded as Bad Debt. 3. Prompt pay discounts will be recorded under Operational Adjustments- Administrative. iv. Under the following circumstances, it can be assumed that the patient qualifies for charity care and associated services recorded as such: 1. Non-covered medically necessary services provided to patients qualifying for state or county programs. 2. Patient bankruptcies. 3. Accounts initially written-off to bad debt and subsequently returned from collection agencies where the patient was determined to have met the financial support criteria based on information obtained by the collection agency. 2 Printed copies are for reference only. Please refer to the electronic copy for the latest version. PAGE 6 OF 9

7 D. Implementation of Accurate and Consistent Hospital Policies a. SJMO will apply written policies for assisting low-income patients in a manner consistent with this policy. b. SJMO will educate staff members who work closely with patients (including those working in patient access, customer service, billing and collections) about hospital billing, financial assistance, collection policies and practices, and treatment of all patients with dignity and respect regardless of their insurance status or their ability to pay for services. c. SJMO will honor charity that was approved under previous financial assistance guidelines. At the end of that eligibility period the patient may be re-evaluated for charity using the guidelines established in this procedure. E. Fair Billing and Collection Practices a. SJMO will implement billing and collection practices for the patient payment obligations that are fair, consistent and compliant with state and federal regulations. b. SJMO will make available to all patients a no-interest, 90 day payment plan with defined payment time frames based on the outstanding account balance. c. SJMO will have written policies about when and under whose authority patient debt is advanced for external collection that are consistent with this policy. d. The following activities may be pursued by SJMO or by a collection agent on their behalf: i. Communicate with patients (call, write, fax, , etc.) and their representatives in compliance with the Fair Debt Collections Act. The patient communications will also comply with HIPAA privacy regulations. ii. Solicit payment of estimated patient payment obligation portion at the time of service in accordance with EMTALA regulations. iii. Provide low-interest loan program for payment of outstanding debts for patients who have the ability to pay but cannot meet the short-term payment requirements as defined in section V. iv. Report outstanding debts to Credit Bureau only after all aspects of this policy have been applied and after reasonable collection efforts have been made in conformance with the SJMO policy. v. Pursue legal action for individuals who have the means to pay but are unwilling to pay. Legal action may be pursued for the portion of the unpaid amount after application of the SJMO financial support policy. An approval by the CEO/CFO, or their direct report, or the functional leader for Patient Financial Services must be secured prior to proceeding with a legal action to collect a judgment (i.e. garnishment of wages, debtor s exam). 2 Printed copies are for reference only. Please refer to the electronic copy for the latest version. PAGE 7 OF 9

8 vi. Place liens on property for individuals who have the means to pay but are unwilling to pay. Liens may be placed for the portion of the unpaid amount after application of the SJMO financial support policy. Placement of liens requires approval by the CEO/CFO, or their direct report, or the functional leader for Patient Financial Services. Liens on primary residence can only be exercised upon the sale of property and will protect the asset value of 50% of the equity up to $50,000. e. SJMO (or a collection agent on their behalf) shall not pursue action against the debtor s person, such as arrest warrants or body attachments. SJMO recognizes that a court of law may impose an arrest warrant or other similar action against a defendant for failure to comply with a court s order or for other violations of law related to a collection effort. While in extreme cases of willful avoidance of failure to pay a justly due amount when adequate resources are available to do so, in general, SJMO will first use its efforts to convince the public authorities not to take action, and, if this is not successful, consider the appropriateness of ceasing the collection effort to avoid an action against the person of the debtor. f. SJMO may have an arrangement with a collection agency, provided that such agreement meets the following criteria: i. The agreement with a collection agency must be in writing; ii. Neither SJMO nor the collection agency may at any time pursue action against the debtor s person, such as arrest warrants or body attachments ; iii. The agreement must define the standards and scope of practices to be used by outside collection agents acting on behalf of SJMO, all of which must be in compliance with this policy; iv. No legal action may be undertaken by the collection agency without the written permission of SJMO; v. Trinity Health Legal Services must approve all terms and conditions of the engagement of attorneys to represent SJMO in collection of accounts; g. All decisions as to the manner in which the claim is to be handled by the attorney, whether suit is to be brought, whether the claim is to be compromised or settled, whether the claim is to be returned to SJMO, and any other matters related to resolution of the claim by the attorney shall be made by SJMO; h. Any request for legal action to collect a judgment (i.e., lien, garnishment, debtor s exam) must be approved in writing and in advance with respect to each account by the appropriate authorized hospital representative as detailed in section V.v; i. SJMO must reserve the right to discontinue collection actions at any time with respect to any specific account; 2 Printed copies are for reference only. Please refer to the electronic copy for the latest version. PAGE 8 OF 9

9 j. The collection agency must agree to indemnify SJMO for any violation of the terms of its contract with SJMO. F. Other Discounts a. Self Pay Discounts: Uninsured patients above 400% of the Federal Poverty Level will receive an automatic 25% discount off charges. b. Prompt Pay Discounts: A prompt pay discount of 10% will be given on balances greater than $200 if the total balance is paid within 30 days of initial billing to the patient. Prompt pay discounts apply to insured and uninsured patients. G. Price Transparency a. SJMO will take positive actions to move forward in the direction of price transparency, these actions include: i. Methods to inform patients of contact information for questions regarding pricing of services. This information should be included in patient communications such as patient bills to inform patients of contact information for questions regarding pricing of services. PROCEDURE None ii. Estimates of total charges for procedures and inpatient stays. The estimates include average charges as well as a range of charges based upon historical information. iii. The charge master will be distributed only with approval by an authorizing member of senior leadership or unless required by State or Federal regulations. RELATED DOCUMENTS 2014 Financial Assistance Matrix REFERENCES Program. (n.d.). U.S. Department of Health & Human Services, 2013 Poverty Guidelines. ASPE. Retrieved July 24, 2013, from 2 Printed copies are for reference only. Please refer to the electronic copy for the latest version. PAGE 9 OF 9