Effective: October 1, 1991 Revised: October 31, 2012

Transcription

1 Revenue Cycle Management Policy and Procedure Policy Number: D Subject: Financial Assistance and Charity Care Policy Page: 1 Of: 6 Effective: October 1, 1991 Revised: October 31, 2012 Approved by: Board of Directors Revised Approval by: Sr VP of Finance and CFO This Financial Assistance and Charity Care Policy of Mission Health is applicable to health care services provided on hospital campus locations (Mission Health). I. POLICY Within the constraints of prudently available resources, it is not the policy of Mission Health to provide relief for medical expenses incurred by families who have access to financial resources to pay in whole for their health care services. Mission Health will balance obligations to provide uncompensated care for patients who are unable to pay with its fiduciary responsibility to preserve assets for serving future patients. Mission Health will make reasonable efforts to screen patients that are uninsured in an effort to identify a source of financial sponsorship. Cases may be reviewed during hospitalization, post discharge upon patient s request or if Mission Health staff identifies an additional need. Only after a final determination is made that the patient is not eligible for any source of funding to cover the medical expenses will a charity care decision be finalized. This policy defines charity care discount parameters for individual patients. Mission Health s free care budget defines annual free care resources available within which management will seek to administer this policy. Charity/free care discounts are determined using criteria such as income, asset and other fund sources availability, considered in relation to the nature and extent of medical services required. Based upon these criteria, patients will be eligible to receive a discount off their total responsibility based on their annualized total income in relation to the most recently published Health and Human Services (HHS) Federal Poverty Guidelines. Charity Discount Amount Percentage of HHS FPG 100% Less than or equal to 150% 75% 151% - 200% 50% 201% - 250% 25% 251% - 300% II. PURPOSE AND GUIDING PRINCIPLES 1. We serve the emergency health care needs of all patients regardless of the patient s ability to pay. 2. For non-emergency health care needs, even for patients who might qualify for discounts, ability to pay for services requested is a consideration for admission and such patients must work collaboratively with a Mission Health Representative to establish appropriate payment arrangements. Financial counseling is provided to patients who seek non-emergency health care services including efforts to help such patients identify available programs or financial assistance for which they might qualify. 3. Upon request, patients are provided detailed charge information in a meaningful format for the charges they incurred for services.

2 Financial Assistance and Charity Care Policy -- #D Page: 2 Of: 6 4. Information regarding Mission Health s Financial Assistance Policy is available via the hospital s web site, financial brochures, during financial discussion with hospital staff and on request. 5. Mission Health staff will work in collaboration with the patient and appropriate community health and human services agencies and other organizations that assist people in need of health care services to determine available funding sources. 6. All policies and procedures applying to financial assistance and financial clearance are applied consistently, which also include reasonable efforts to ensure that financial assistance is offered before any collection agency assignment. 7. Mission Health staff members who work closely with patients are educated and trained about billing, financial assistance and collection policies. 8. All patients are afforded an opportunity establish reasonable payment plans. 9. Mission Health reserves the right to pend a final decision or reverse a charity / free care discount previously recorded if it is determined that additional third party payer resources were available, or that some information provided may be false. Patients will be notified and afforded an opportunity to provide clarification. 10. Mission Health reserves the right to require proof of income and assets, not normally required, if there is reason to believe the information provided is not complete and accurate. D. DEFINITIONS A. Eligible Account An eligible account is any account of a patient of Mission Health where there is an outstanding balance due from the guarantor and where the annualized total income (based on Mission Health s procedure for calculating income) is below 301% of the Federal Poverty Guidelines for the patient s family/household. Any discounts or discounts negotiated with patients, third party payers, employers, attorneys, etc. are not governed under this policy. B. Family/Household The family/household is inclusive of those living in a home comprising a single family. Dependents of the financially responsible party are also included regardless of their residence. Examples of individuals which can be included as members of a family/household include (but are not limited to): Patient Spouse Partner sharing the home Mother/Legal guardian of dependent child(ren) 17 years old and under Father/Legal guardian of dependent child(ren) 17 years old and under Dependent children 17 years old and under Disabled adult dependents receiving federal disability income

3 Financial Assistance and Charity Care Policy -- #D Page: 3 Of: 6 C. Federal Poverty Guidelines The standards used by the United States Department of Human and Health Services (HHS) for determining whether a person or family is financially eligible for assistance or services under a particular federal program. The Federal Poverty Guidelines (FPG) is updated annually by HHS, and is published in February, March or April of each year in the Federal Register. D. Charity Care When Mission Health qualifies a patient for charity care based on approved qualification criteria, the hospital agrees to accept less than full compensation for outstanding charges due from the patient. Full compensation shall mean the amount of money that Mission Health would be entitled to receive for a particular health care service or product if no discounts were applied. An application is initiated by completion of the Financial Statement. III. PROCEDURE FOR DISCOUNT DETERMINATION A. Emergency Services. 1. Mission Health fully complies with all obligations imposed by the Emergency Medical Treatment and Active Labor Act ( EMTALA ) and related regulations including but not limited to providing without regard to a patient s ability to pay (and without the necessity of any pre-treatment financial screening) the provision of a medical screening exam to any patient who comes to the Mission Health emergency departments and requests an examination or treatment for a medical condition, including active labor, and the provision of either stabilizing treatment or an appropriate transfer for patients with emergency medical conditions. B. Discount Determination Procedures 1. Mission Health may automate some financial assistance determinations. Patients may appeal automated decision for manual review. 2. Any patient who has or anticipates incurring financial obligations to Mission Health for medically necessary services, may at any time (preadmission, during the course of a hospitalization or at any time after discharge) request a determination for qualification for financial assistance. This policy applies to both patients with and without insurance benefits. Medically necessary services are determined by a physician or by preauthorization, (even if authorization is reversed after services are provided). 3. All insured patients with a denied claim, which leaves them responsible for the total charges, are eligible to apply for a financial assistance discount. 4. For charity care eligibility, the assessment of the annualized total income and assets of those legally liable for health care services will be required. This may include those that have signed a Potential Health Plan Denial (PHPD), those that have signed an Advance Beneficiary Notice (ABN), the patient, the financially responsible party, or a spouse if living in the household or legally responsible for the health care debt. 5. Upon evaluation of the annualized total income and assets, the patient will be eligible for a 25%, 50% or 75% discount if total income is between 151% and 300% of the most recently published HHS Federal Poverty Guidelines. The patient will be eligible for a 100% discount if income is less than 151% of the most recently published HHS Federal Poverty Guidelines. A Self-Employed patient s annualized income will be calculated based on the total income

4 Financial Assistance and Charity Care Policy -- #D Page: 4 Of: 6 reflected on their most recent tax return. Patients with a balance due greater than $10,000 with a gross annualized total income greater than 300% of the most recently published HHS Federal Poverty Guidelines may be eligible for a discount under the catastrophic provision of this policy. 6. Some situations qualify for a 100% indigent discount and do not require an application or supporting financial documentation. Account notes and medical records will support eligibility determination for homeless patients, Medicaid eligible patients with residual balances, incarcerated patients, patients in treatment programs, deceased patients or patients in situations that make it impractical to apply for charity care. 7. Other situations qualify for a 100% indigent care discount and do not require an application or supporting financial documentation. In these situations, qualified hospital staff will reasonably determine indigent status using due diligence, documenting their findings based on available information in the account notes, medical records and external sources. 8. In addition to other discounts described in this policy, patient balances of $10,000 or greater will be eligible for a catastrophic discount. In order to qualify, the patient s balances due must exceed $10,000 after other discounts, a completed financial statement must be signed by the guarantor, and all income and assets must be verified. Upon meeting these requirements, the patient s balance due will be discounted such that after other discounts in this policy have been applied, the remaining balance will not exceed 25% of the annualized total income, as documented on the signed financial statement. 9. To complete the discount determination process, an applicant must cooperate fully with Mission Health staff and other potential payers to exhaust the possibility of qualifying for third party payment for medical services requested or received. 10. An essential element of the financial assistance process involves provision by the patient of complete information and verification as needed about all relevant income and asset information for the patient and anyone else financially obligated for payment of the medical services requested or provided. This information includes but is not limited to completion of the Financial Statement and provision of any related verifications requested. Additionally, if the discount amount is less than $3,000, the patient is not required to sign the Patient Financial Statement. 11. The financial assistance determination process involves consideration of both assets and total income. The assessment of assets is an inherently subjective determination made by Mission Health at its discretion taking into account a variety of factors believed to be relevant including but not limited to the nature and extent of the assets, the magnitude of the patient s financial obligation to Mission Health, the impact of the assets on the patient s eligibility for coverage of medical expenses by other third party payers such as Medicaid, the nature and extent of the financial needs for which the assets are currently utilized and the age and income of the patient and/or other responsible parties. The applicant s cash on hand and assets will be valued in accordance with the Mission Health Cash and Asset Allowances and Exclusions. 12. Patients who are provided discounts will be notified in writing, via a patient statement for remaining balances due or a letter for a 100% discount, as to the amount of the discount and any residual balance owed to Mission Health.

5 Financial Assistance and Charity Care Policy -- #D Page: 5 Of: All discounts as reductions in the patient s financial obligation to Mission Health will be credited to the patient s account. A record of all discounts written off pursuant to this policy will be maintained. 14. Only the patient account balance owed after insurance payments and applicable adjustments are applied to the account will be subject to discount consideration. 15. Patients approved for a discount pursuant to Mission Health Financial Assistance and Charity Care Policy will be re-evaluated for financial assistance when they require future services after 120 days from last discount approval date. If the patient is receiving a Medicare check for retirement or disability benefits or is receiving an SSI monthly check, the charity approval will be valid for one year versus a 120-day period. All outstanding debts on previous charges will be subject to the approved discount percentage with the exception of accounts previously placed with an attorney for legal action or accounts where the patient is deceased with an outstanding estate. A guarantor may re-apply for financial assistance when total income, household family unit, or personal property changes in a manner that warrants re-evaluation. C. Control Mechanisms 1. Any person with authorized approval to sign off on charity care discounts will be prohibited from taking applications and/or making recommendations for charity care write offs on their family members and friends. These applications must be referred to another staff member for determination and completion. If any relationships/situations are questionable, they should be forwarded to another authorized person for completion. Violations will warrant disciplinary action. 2. Once a financial statement is completed and signed and a determination is made regarding qualification for a discount, proof of income and assets will be required when the total amount of the pending charity care discount is greater than $3,000. Additionally, if the charity care discount is less than $3,000, the patient is not required to sign the financial statement. 3. A Revenue Cycle management team member will conduct quarterly departmental audits of five random charity care applications that do not require management level approval (less than $5000), to include at least one application that was denied, and will examine the corresponding total income and assets for reasonableness. The audit will be conducted in the month of October 2012 and within the following months at quarterly intervals. Results will be shared with a designated Director of the Revenue Cycle followed by remedial education as appropriate. 4. Approval levels for Mission Hospital and McDowell Hospital are: $1 - $3,000 Designated Collection Representatives $3,001 - $5,000 Designated Financial Assistance Coordinators, Coordinator of Specialty Collections $5,001 - $20,000 Designated Revenue Cycle Supervisor $20,001 - $50,000 Designated Revenue Cycle Manager

6 Financial Assistance and Charity Care Policy -- #D Page: 6 Of: 6 $50,001 - $100,000 Designated Revenue Cycle Director Over $100,000 Vice President of Revenue Cycle Management 5. Approval levels for Transylvania Hospitals are: $1 - $5,000 Designated Collection Representatives $5,001 - $20,000 Designated Revenue Cycle Supervisor or Team Leader $20,001 - $50,000 Designated Revenue Cycle Manager Over $50,000 Chief Financial Officer / Vice President 6. Mission Health Financial Assistance and Charity Care Policy will be reviewed at least annually by the Vice President of Revenue Cycle Management and recommendations for revisions, updates and/or confirmation of no changes to the policy will be made and forwarded to the Sr. Vice President of Finance and CFO for review and approval/signature. Effective: 12/1/07 Reviewed: 10/91, 1/05, 10/06, 9/07 8/09, 11/10, 4/11, 6/11, 11/11, 9/10/12, 10/31/12