PURPOSE POLICY DEFINITIONS

Transcription

1 PURPOSE To assure that financial assistance options are available to all uninsured, financially indigent, and medically indigent patients and guarantors who are unable to pay for medically necessary services rendered at any health care facility, including hospitals, outpatient clinics, skilled nursing facilities, substance abuse units, behavioral units and transportation services of Lester E. Cox Medical Centers ( Cox ), CoxHealth Branson, and Cox Monett Hospital, while ensuring Cox s compliance with State and Federal laws and regulatory guidance pertaining to financial assistance. Services provided in a facility not owned by Cox (such as a private physician s office) are not subject to this Policy and Procedure. The purpose of this Policy and Procedure is intended solely for the benefit of patients and any acceptable guarantor for debts incurred due to medical or surgical services. This Policy and Procedure is not to be construed to benefit third parties such as insurance companies or others who are obligated to indemnify the patient for health care expenses. POLICY Financial assistance, including discounted medical services, waivers of certain fees and financial counseling are made available to all patients or guarantors who meet eligibility criteria outlined in this Policy and Procedure. DEFINITIONS The following definitions apply to all sections of this Policy and Procedure: 1. Authorized Party means those persons employed by Cox as Financial Advisors or other authorized entity Financial Counselors, Supervisors, Managers, Directors, and the Chief Financial Officer who have the authority to award Financial Assistance to guarantors pursuant to this Policy and Procedure. 2. Episode of Care means a single visit to an outpatient clinic, physician clinic, a single hospital stay, or series. Care provided by a physician during a hospital stay is a separate Episode of Care from the single hospital stay. An Episode of Care may occur one time or several times during one twenty-four (24) hour day. A series is defined as a single month of treatment for the same medical diagnosis in which the patient is seen 2 or more times per week for the same service. 3. Federal Health Care Program means any healthcare program operated or financed at least in part by the federal, state, or local government, including but not limited to Medicare, Medicaid, SCHIP, Healthcare Exchange Insurance and Tricare (CHAMPUS). 4. Federal Poverty Guidelines means those guidelines issued by the United States Department of Health and Human Services from time to time that describe poverty levels in the United States based on a person or family s household income. The Federal Poverty Guidelines are adjusted according to inflation and published in the Federal Register. For the purposes of this policy, the most current annual guidelines will be utilized. 5. Financial Assistance is the broad term that means a reduction in a patient or guarantor s bill in accordance with this Policy and Procedure. 6. Guarantor means any acceptable party, including but not limited to the patient him/herself, parent or guardian who guarantees the payment of a debt incurred by the patient who received services covered by

2 this Policy and Procedure. Guarantor also includes any community or communal-living funds or assets that are available to satisfy all or a portion of a debt incurred by the patient. 7. Insured Patient means an individual who has third-party coverage by a commercial insurer, an ERISA plan, A Federal Health Care Program, Worker s Compensation, Medical Savings Accounts, or other coverage for all or part of his or her medical bills. 8. Medically Necessary Services are services or supplies needed for the diagnosis or treatment of a patient s medical condition and are not used primarily for convenience and are not considered an experimental or excessive form of treatment. Any uncertainty of medical necessity can be directed to the department head or designee of the department who provided the service. 9. Service Area means the geographic area served by Cox facilities. This area has been defined to include the following counties in southwest Missouri: Barry, Cedar, Christian, Dade, Dallas, Douglas, Greene, Hickory, Howell, Jasper, Laclede, Lawrence, Newton, Ozark, Polk, Pulaski, Stone, Taney, Texas, Webster, and Wright. The following counties in northwest Arkansas are also included in Cox s Service Area: Baxter, Boone and Carroll. 10. Uninsured Patient means an individual who is uninsured, having no third-party coverage by a commercial insurer, an ERISA plan, a Federal Health Care Program, Worker s Compensation, Medical Savings Accounts, or other coverage for all or part of his or her medical bills, including claims against third parties covered by insurance to which Cox is subrogated. However, for the purposes of this Policy and Procedure, a patient who has coverage will be deemed to be uninsured for services for which he or she has no benefit under his or her plan, so long as such non-covered services are medically necessary and not considered (in hospital s sole discretion) to be elective, experimental or cosmetic in nature. 11. Underinsured Patient means, for the purposes of this Policy and Procedure, an individual whose insurance coverage is limited such that after payments by the third-party coverage have been made, the patient or guarantor is still left with out-of-pocket expenses in excess of $10,000. These individuals may apply for financial assistance and be assessed under the medical indigence criteria outlined in this policy for hospital services. 12. Amounts Generally Billed will be calculated utilizing the Look Back Method. This is a percentage calculated no less frequently than annually by dividing the sum of commercial and Medicare claims paid to the hospital facility by the sum of the associated gross charges for those claims. Cox will make this calculation on or about August 15th of each year and begin applying its AGB percentage(s) by October 1st. FAP eligible individuals will not be charged more than the amounts generally billed (AGB) for emergency or other medically necessary care. FINANCIAL ASSISTANCE OPTIONS In general this policy does not provide for discounts of 100%. Therefore it is expected that the patient or guarantor will hold a responsibility for payment of services regardless of the level of eligibility. It is our intention to work with individuals on their out-of-pocket responsibility to establish feasible monthly payments when necessary. In the event that a patient or guarantor is determined to have no means of paying the amount indicated as their responsibility due to extenuating circumstances, consideration may be given to waiving deductibles and/or increasing the discount amount up to a 100% discount of the patient portion. These extenuating cases are subject to the discretion and approval of the Patient Access Director and/or the Chief Financial Officer within the approval limits defined at the end of this policy.

3 The following options (categories) are used to distinguish the difference between financial assistance options. The indigent terms are internal terms used to distinguish the difference in the financial assistance categories under which an application for financial assistance will be examined. However, for the purpose of communicating with customers, to avoid confusion or misunderstanding, it is best to use the broader term financial assistance. 1. Financially Indigent An uninsured patient whose household income falls between 0 to 300% of the federal poverty guidelines or whose bill exceeds an amount of $50,000 may qualify for a financial assistance discount on their bill. The discount guidelines include 6 separate levels based on a range of the Federal Poverty Guidelines. These discount options are illustrated in Exhibit A, Financial Assistance Program Guidelines. 2. Medically Indigent An underinsured patient, as defined in this policy, may qualify for a discount on the portion owed by the patient or guarantor for hospital services if the financial responsibility exceeds $10,000. In such a case, the individual may apply using the same application criteria as any other financial assistance application. If eligible, the patient debt per episode will be discounted to an amount equal to $10,000 or the equivalent of the annual household income, whichever is greater. 3. Uninsured Discount Any uninsured individual who does not meet the preceding financial assistance qualifications or does not participate in the financial assistance application process is eligible for a 64.3% discount off of billed charges for hospital services in Springfield; 54.94% discount off of billed charges for hospital services in Monett; and 69.73% discount off of billed charges for hospital services in Branson. This discount is an alternate to the above guidelines and is not to be used in addition to. In the event a patient who has received an uninsured discount is later determined to be insured for the services discounted, the uninsured discount is no longer valid and will be reversed. At that point, the services will be billed to the third-party payer. NOTE: These uninsured discounts are determined based on a retrospective analysis of the commercially insured payment data for the second fiscal year prior to implementation and will be updated annually to be effective at the beginning of each fiscal year. The initial update to these discounts occurring in accordance with the 2010 healthcare reform legislation will be initiated in advance of the mandated implementation date of October 2010 and will also be retrospectively applied to services occurring on or after October 1, All discounts are reviewed periodically and subject to change at the discretion of Cox. PROCEDURE 1. Eligibility (a) Guarantors (including the patient) may be screened for eligibility for Federal Health Care Programs that may assist them in paying for medical services. Before guarantors are eligible for Financial Assistance, he or she must apply (and follow through within a reasonable time on all applications) for any Federal Health Care Programs for which they may be eligible including but not limited to Healthcare Exchange plans if within the open enrollment period. Guarantors who are not eligible for Federal Health Care Programs and are otherwise considered uninsured or underinsured may be eligible for Financial Assistance under this Policy and Procedure.

4 Cox offers eligibility screening services through on-sight Case Management Staff, Financial Counseling, and/or a contracted Eligibility Vendor. In the event a patient is fully screened by one of these groups and is pre-determined not to qualify for any Federal Health Care Programs, a notice of ineligibility (through a standard form or letter) from these groups may be accepted as proof of ineligibility for the Federal Health Care Programs. These groups must use caution to assure screening is complete and thorough prior to making a determination. (b) Medically necessary services for which Medicaid does not provide coverage is automatically eligible for financial assistance for those individuals who are verified as Medicaid eligible/enrolled. This may include, but is not limited to, services such as therapy and certain ambulance services. These patients are not required to complete the application process for these services because verification of Medicaid eligibility confirms their eligibility for Financial Assistance based on the income guidelines. (c) Guarantors who may apply for Financial Assistance on behalf of the patient include the patient s parents (birth, adoptive or step parents) and legal guardians, or those having valid powers of attorney. (d) Guarantors seeking Financial Assistance must cooperate and participate in the initial screening process in order to remain eligible for Financial Assistance. Guarantor cooperation and participation includes providing the documentation necessary to make eligibility decisions within fifteen (15) days of the request for such documentation by a Cox representative. The Cox representative assigned to the case will make a reasonable attempt to obtain any missing information from the initial application by sending a written notice to the guarantor or contacting the guarantor by phone. However, if the required documents are not received after the second attempt, the application will be denied. The patient may reapply if he/she has future services. (e) Failure to cooperate with the application requirements may result in ineligibility for Financial Assistance. (f) Financial Assistance is only available for medically necessary procedures or services. Therefore, charges for any elective or cosmetic procedures or services will not be eligible for reduction by Financial Assistance. Weight loss surgery and related procedures and/or treatment(s) are not eligible for financial assistance under this policy. (g) Once an application for Financial Assistance has been submitted, the patient or guarantor will be asked to complete a Financial Assistance Attestation Statement when presenting for any future services until the term of the Financial Assistance has expired. The purpose of the attestation is to have the patient or guarantor acknowledge the new services and the request to have the charges included in Financial Assistance as well as attest to their current financial state as compared to their financial status at the time of application. (h) Eligibility for Financial Assistance expires at the earlier of the following events: (i) Twelve (12) months from the date of Financial Assistance determination/redetermination; or

5 (ii) Change in the guarantor s financial circumstances (i.e. ability to pay, eligibility to participate in Federal Health Care Programs that would otherwise affect guarantor s ability to receive Financial Assistance or the amount of Financial Assistance granted) as identified through the Financial Assistance Attestation Statement or other notification; or (iii) The referral of guarantor s outstanding debt to a collection agency or the Cox Collection Department. However, Cox has the discretion to grant Financial Assistance to some guarantors following referral of the guarantor s account to the Collection Department. These determinations are made on a case-by-case basis. (i) To be eligible for Financial Assistance, guarantors must demonstrate that they reside within the Cox Service Area. However, guarantors residing outside of the Service Area may be eligible for Financial Assistance for services provided in emergent situations. 2. Determinations Regarding Financial Assistance Amounts (a) Financial Assistance is awarded to guarantors based on the guarantor s household income level as a percentage of the Federal Poverty Guidelines. In order for this determination to be made, guarantors must provide proof of their income and residence prior to receiving Financial Assistance. (i) With the exception of the Uninsured Discount, all determinations of eligibility for Financial Assistance, regardless of the amount of debt incurred, shall be made on an individualized, caseby-case basis. Cox does not routinely grant Financially Indigent or Medically Indigent Financial Assistance awards to any guarantor or class of guarantors without some level of individualized determinations. (ii) In addition to the Federal Poverty Guidelines, Authorized Parties who determine eligibility for Financial Assistance for all hospital services and physician office services, excluding those physician offices employing physicians who are receiving National Health Service Corps Loan Repayment, may also examine the following in making their determinations: local cost of living, the guarantor s assets and other expenses such as alimony, child support, rent and the scope and extent of the patient s medical bills. (iii) All documentation which is obtained from the guarantor demonstrating eligibility for Financial Assistance shall be maintained within the patient s billing file. Such documentation may include a copy of determination letters from Medicaid (where applicable) or notice of ineligibility from Case Management, Financial Counselor, or Eligibility Vendor; copies of paycheck stubs; financial records such as tax returns or other documents demonstrating financial need and all correspondence between Cox and the guarantor pertaining to the guarantor s debt. (iv) Financial information must be verified on all guarantors seeking financial assistance; selfattestation of need will not be sufficient for the grant of Financial Assistance. (v) The applicant s account activity for the two years prior to the application date will be reviewed for bad debt adjustments. Those bad debt adjustments will be returned from the collection agency and become eligible for inclusion in the financial assistance process. (b) All guarantors selected to receive Financial Assistance will be notified in writing by Cox s Financial Services department. This letter will inform the guarantor of the amount of Financial Assistance for which he/ she has been approved. Best efforts will be made to provide this notification within 30 days from receipt of the completed application. Billing statements will further reflect the

6 amount of the Financial Assistance award, if any. For those guarantors who qualify for Financial Assistance of 100% of billed charges pursuant to this Policy, such that their balance is $0, billing statements will not be mailed. (c) Any account for which Financial Assistance has been approved will be excluded from any form of applicable interest assessment. If interest has accrued prior to approval, it will be removed. However, in accordance with section V.B., interest may be assessed at a later time at Cox s sole discretion if the guarantor defaults on his or her payment plan or the balance is referred to the collection agency for non-payment. (d) Where the recipient of Financial Assistance is dissatisfied with the amount of Financial Assistance granted, or the initial determination of eligibility for Financial Assistance, the application will be referred to the Patient Access Director or Vice President of Revenue Cycle for further consideration (e) The discount amounts generally available to guarantors range from 40% to 95% less any applicable guarantor responsibility, identified as a deductible. Therefore, it is expected that the guarantor will hold a responsibility for payment of services regardless of the level of eligibility and will be subject to the standard collection policy and procedure for any amount left unpaid. (f) Exhibit A, Financial Assistance Program Guidelines, is a table that demonstrates the various levels of discount and guarantor responsibility associated with the Federal Poverty Guidelines and the hospital maximum out-of pocket criteria. This table is to be utilized by the financial counselors in determining the level of eligibility for each guarantor. The table must be updated annually, within 60 days, of the latest Federal Poverty Guidelines being published. The following explains the key elements of the table: Guarantor Deductibles: Physician: The amount of guarantor responsibility for each episode of physician care that is applied before discounts are calculated. This includes physicians services performed at any location (i.e. clinic, hospital). Hospital: The amount of guarantor responsibility for each episode of hospital care that is applied before discounts are calculated. Discount: The percentage of discount applied to the total charges after the deductible is reflected. An additional discount may apply if the Hospital Maximum is exceeded (see below). Hospital Services Out-of-Pocket Maximum: The maximum amount of guarantor out-of-pocket responsibility for a single episode of care. If this amount is exceeded in the standard calculation, an additional discount will apply. (g) The following parties are authorized to grant Financial Assistance awards, each of which is limited as follows. The majority of cases will not require more than supervisor approval as long as the case falls clearly within the Financial Assistance guidelines and normal procedures. If a case appears to be an exception or has unusual circumstances, higher level approval is required as indicated. Authorized Party Amount Party May Authorize Financial Counselors $1- $14,999.99

7 Supervisors $15, $29, Patient Access Director $1- $49, (exceptions only) VP, Revenue Cycle $50,000 or more (exceptions only) Each authorized party is responsible for assuring all eligibility requirements according to this policy are met prior to approval and adjustment of any debt. All approvals are subject to routine and random QA audits. (h) Cox recognizes that catastrophic injuries or diseases may occur such that even guarantors who otherwise would not be eligible for Financial Assistance under this Policy and Procedure are unable to pay large medical bills. Where guarantors fail to meet the criteria outlined, a guarantor s request for Financial Assistance is to be referred to Cox s Chief Financial Officer. In such cases, only the Chief Financial Officer, Chief Operating Officer or Chief Executive Officer has the discretion to determine that a guarantor qualifies for financial assistance. As with any other eligibility determination, all documentation provided for determination must be maintained within the patient s billing file. 3. Determination Review and Re-determinations (a) Guarantors must submit new or updated documentation every twelve (12) months. Guarantors also must attest at each visit that there has been no material change in his/her ability to pay since the initial determination and grant of Financial Assistance. Any material change in the guarantor s income or ability to pay will warrant a redetermination of the Financial Assistance award. (b) Re-determinations can increase or decrease the amount of Financial Assistance previously awarded. Such re-determinations may take place at any time, including each twelve-month review of determinations or upon notification of material change in the guarantor s income or ability to pay. 4. Collection Efforts (a) Cox will not pursue legal action for nonpayment of any amounts discounted as a result of an approved or partially approved request for financial assistance. Balances remaining after such discounts are applied will, however, be subject to collection activity, including legal action. (b) Cox will not charge interest on the balance remaining after applying the financial assistance discount. However, Cox may, in its sole discretion, charge interest on the balance owed if 1) the guarantor defaults on his or her payment agreement or 2) the balance is referred to the collection agency for collection. (c) Cox prohibits engaging in collection activity in the Emergency and Urgent Care Departments from individuals seeking emergent or urgent medical care before the individual has been triaged and seen by a licensed physician, Nurse Practitioner or Physician Assistant. COMMUNICATION OF THE FINANCIAL ASSISTANCE PROGRAM Notification about financial assistance available from Cox which shall include a contact number, shall be disseminated by Cox through various means, which may include, but are not limited to, the publication of notices in patient bills and by posting notices in emergency rooms, in the Conditions of Admission form, at urgent care centers, admitting and registration departments, hospital business office and patient financial services offices that are located on facility campuses, and at other public places as Cox may elect. Cox 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 Cox may elect. Such notices and summary information shall be provided in the primary

8 languages spoken by the population serviced by Cox. Referral of patients for financial assistance may be made by any member of the Cox staff or medical staff, including physicians, nurses, financial counselors, social workers, case managers, chaplains, and religious sponsors. A request for financial assistance may be made by the patient or a family member, close friend, or associate of the patient, subject to applicable privacy laws. PRESUMPTIVE FINANCIAL ASSISTANCE ELIGIBILITY There are instances when a patient may appear eligible for financial assistance discounts, but there is no financial assistance form on file due to a lack of supporting documentation. Often there is adequate information provided by the patient or through other sources, which could provide sufficient evidence to provide the patient with financial assistance. In the event there is no evidence to support a patient s eligibility for financial assistance, Cox could use outside agencies in determining estimate income amounts for the basis of determining financial assistance eligibility and potential discount amounts. Once determined, due to the inherent nature of the presumptive circumstances, the only discount that can be granted is a 100% write off of the account balance. Presumptive eligibility may be determined on the basis of individual life circumstances that may include: 1. State funded prescription programs; 2. Homeless or received care from a homeless clinic; 3. Participation in Women, Infants and Children programs (WIC); 4. Food stamp eligibility; 5. Subsidized school lunch program eligibility; 6. Eligibility for other state or local assistance programs that are unfunded (e.g. Medicaid spend down); 7. Patient is deceased with no known estate.

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