I. POLICY: II. PURPOSE:

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1 DEPARTMENT: Patient Financial Services SUBJECT: Financial Assistance POLICY: SCOPE: All Departments EFFECTIVE DATE: 03/21/2013 APPROVED: 03/21/2013 I. POLICY: In recognizing the medical needs of the indigent, West Georgia Health provides necessary quality medical care, regardless of race, creed, color, sex, national origin, sexual orientation, physical ability, age, or ability to pay. Although reimbursement for services rendered is critical to the operation and stability of West Georgia Health, it is recognized that not all individuals possess the financial ability to purchase essential medical services. Therefore, in keeping with West Georgia Health s commitment to serve all members of the community, a reduced fee agreement will be considered in situations where the need and the inability to pay coexist. The healthcare services provided will be reimbursed at a reduced level based on established income criteria as defined in this policy. West Georgia Health will not pursue legal action against the charity portion of a patient s bill. II. PURPOSE: West Georgia Health recognizes its responsibility to the community by insuring that patients requiring necessary medical care are not denied services based solely on a lack of financial means. The necessity for medical treatment of any patient will be based upon clinical judgment and could exclude elective procedures. West Georgia will provide medical care at a reduced rate to those patients who have documented limited resources to pay for the facility s usual and customary charges as approved by hospital management. III. ELIGIBILITY CRITERIA: A. All self-pay inpatient, outpatient and emergency department patients will be screened by West Georgia Financial Counseling Team to determine the patient s need for financial assistance. 1. The first level of screening for assistance is conducted by the Customer Service Center and/or Patient Access Staff with the patient and/or their representative to determine potential linkage to a government program. (Exhibit G)

2 a. If the initial screening indicates the patient may qualify for a government program, including Georgia Medicaid, SSI/SSDI, ODD, or VOC, the Customer Service Team are responsible for assuring appropriate applications are completed and signed, including authorized representative forms, and medical referrals if applicable. b. The accounts will be categorized in Meditech based on the payor indicative of the eligibility link. C. the Customer Service Center follow established protocols and timelines for follow-up, monitoring, documentation, and conversion of accounts within the Meditech Desktop module. 2. The second level of screening for the self-pay patient needing financial assistance is to determine whether any alternative forms of financial assistance are available. Customer Service Center or PAS Staff will use a Financial Assistance Application (Exhibit F) and supporting documentation to gather information necessary to identify eligibility for the alternative forms of financial assistance. This information will include: a. The patient whose income is below 125% of the Federal Poverty Guidelines (Exhibit A) may qualify to have all debt incurred forgiven. Those patients with income above 125% but not exceeding 375% of the Federal Poverty Guidelines may qualify for a reduction of their debt based on a sliding scale. A patient may also receive a reduction of their debt if they have a catastrophic medical occurrence. b. The number of people in applicants family unit is determined based on the definition that the family unit consists of individuals living alone; and spouses, parents and their children under the age of 21 living in the household. c. Calculation of income for the family unit is determined by the family unit s gross income, based on the average monthly income for the previous three months or for the previous year, whichever is more favorable to the client. Income may not be counted from any person who is not financially responsible for the patient. For self-employed individuals, income is calculated as gross income minus work expenses directly related to producing the goods or services. d. Verification is required of each source of current income for all members of the family unit. Acceptable documentation for verification includes: 1) Pay stubs for the past 3 months or last tax return 2) W-2 form from prior year 3) Copy of pension check or Social Security check 4) Child support statement 5) VA statement

3 6) Unemployment earnings 7) Compensation earnings 8) Earnings statement if self-employed e. If patient/guarantor is unable to provide the above documentation to verify income, an original letter from his/her employer on company letterhead should be provided showing part-time or full time status, length of employment and monthly income. If the patient is not able to provide any documentation of income verification, the patient must supply a letter containing all facts supporting the need for financial assistance. Approval with this documentation will be on a case-by-case basis. f. The applicant s statement of zero income may be accepted if submitted as a notarized statement. g. If the income verification process reveals an error in income reporting, the applicant will be requested to correct the information. If the applicant s attestation does not match income verification, the applicant may be ineligible for financial assistance. 3. Tools used to determine levels of financial assistance include: a. Federal Poverty Guidelines obtained annually at (Exhibit A) b. Sliding Scale for West Georgia Health based on Poverty Guidelines (Exhibit A) c. Payment Plan Arrangements Guidelines (Exhibit B) 4. The accounts will be categorized in Meditech based on the level of assistance indicative of their eligibility application. The Customer Service Center will follow established protocols and timelines for follow-up, monitoring, documentation, and conversion of accounts within the Meditech Desktop Module. 5. A patient who does not qualify as financially needy, but whose patient responsibility payments specific to treatment at WGH for medically necessary services, even after payment by third-party payers, exceed 30% of the family unit s gross income will be recognized as having a catastrophic medical expense. Any patient responsibility for services within a 12-month period may be written off to Financial Assistance under the catastrophic expense. 6. If a patient is receiving care at WGH Community Service Clinic and the clinic refers the patient to the hospital for a medically necessary treatment or procedure, the account will be considered charity without requiring duplicate documentation. 7. Hospice qualifications for assistance under the Hospice Charitable Trust, including asset verification, are outlined in Exhibit C. If a hospice patient acquires a balance that is not subject to coverage under the charitable trust

4 guidelines, the patient will be screened for eligibility per this policy (by hospice staff). Any approved amounts will be adjusted utilizing a hospice charity adjustment code. 8. If all levels of financial assistance are exhausted, patients may establish a payment plan to resolve the balance of their account(s). (Exhibits B and H) These patients will be designated in Meditech as a payment arrangement account to allow identification as the accounts progresses through the collection cycle. IV. NON-ALLOWABLE: The following are not covered by this policy: A. Amounts due to the hospital and collectable from third parties such as insurance, Workers compensation, medical benefits, etc. The patient may be eligible if balance remains. B. Patients who qualify for Medicaid-Patients who do not fully comply with the Medicaid application process requirements will be excluded from financial assistance eligibility. B. Nursing Home Patients with exception of self pay WGH transfers that meet Financial Assistance criteria. Nursing Home patients may be screened for Medicaid and Charity assistance under the guidelines of this policy however any charity adjustments to SNF accounts will be adjusted using a SND charity adjustment code and excluded from the ICTF data collection. C. Innocent crime victims, who refuse to press charges or initiate legal action against their assailant, if known, will not be considered for assistance. D. With the exception of emergencies, patients not considered to be a U.S. citizen or patients living outside the following counties: Troup, Meriwether, Heard, Harris, Chambers, Randolph will not be considered for financial assistance. (The county exclusion is not applicable to Hospice patients in Coweta County.) V. PROCEDURE: A. Individual notification of this policy will be given at registration to all patients (or their representative) seeking services or having services at West Georgia Health via Meditech generated informational handouts and patient handbooks. B. Information and applications for financial assistance are available in any Patient Access Area Department. An application will also be completed electronically during

5 the registration process on self-pay accounts. The availability of financial assistance from West Georgia is communicated to the community by annual notification in the local, general circulation newspaper, on the hospital internet site, and via postings in intake areas. The policy owner at WGH assures the updates and revisions to public communications are completed each year at policy review. C. West Georgia Health provides assistance to medically indigent patients by operating a program that meets the requirements of the Indigent Care Trust Fund of Georgia, and as funds are available from the program, a certain amount of services are made available through special funding from the program. D. Walk-ins requesting financial assistance will be seen by the appropriate departmental personnel depending upon the availability of time, or an appointment will be scheduled for the individual to meet appropriate department personnel at a later time. D. The Customer Service Team will review inpatient census activity reports daily of uninsured or underinsured patients, and then an interview will be conducted with patient or patient s representative or contact established and follow up by phone or letter for established assistance links. Outpatient accounts will receive correspondence and education regarding the financial assistance program at the time of registration, with their first statement and on each collection letter sent, while the account is in house or with the Patient Service Center. E. All outpatient self-pay accounts will be engaged in the financial assistance notification process via an automatic letter series initiated at registration and continuing through the internal collection process, up to referral to an external collection agency. Accounts may also be referred from Patient Service Center to the Customer Service Center for financial assistance engagement. F. Applications submitted without supporting documentation will be reviewed for conditional eligibility. However, applications will only be deemed complete for final consideration upon submission of the application and all supporting documentation. Determinations of eligibility are made within 5 working days from the date of application completion. The Log of Patient Accounts is adjusted to reflect the final determination when it is made. F. The WGH Sliding Scale (Exhibit A) will be updated each year by the PFS Director using the annual revision of the Federal Poverty Guidelines as published yearly in the Federal Register by the Department of Health and Human Services. G. The amount of the discount calculated utilizing the sliding fee scale will be adjusted off using the appropriate adjustment transaction code. H. If the patient has a debit balance; WGH may set up payment arrangements based on Exhibit B and H.

6 I. Hospital administration has the final authority to approve or reject any specific application for financial assistance. J. Applications are accepted at any time, including after initiation of a collection effort, however those accounts that have been categorized as bad debt will not be eligible. K. Notices are sent to applicants informing them of results of the financial assistance determinations. If an applicant is determined ineligible for any available program, the reasons and the information relied upon to make the determination are included. The information provided in the Financial Assistance determination notice also includes details on how to be reconsidered and contact information if the patient disagrees with the final decision. The Customer Service Center Supervisor will review all applications and indicate approval determination based on the guidelines of this policy. All reconsiderations will be routed to the Patient Financial Services Director. In all instances, someone different from the person who made the initial determination of eligibility will be appointed for the reconsideration. (Exhibits I J) VI. APPLICATION PROCESS: A. All patients applying for financial assistance must submit a completed Financial Assistance Application Form (Exhibit F). B. At any time the family unit s financial circumstances change, a new application for Financial Assistance may be submitted. The Poverty Income Guidelines in effect the day WGH receives the completed application will be used to make eligibility and award determinations. These Poverty Income Guidelines are revised annually. C. If the family unit income is above the guidelines or the required documentation has not been received within 30 days of the date on the submitted application, the application will be denied, and the patient will be notified in writing. The collection cycle will continue on all accounts throughout the determination process. D. For patient with third party coverage, all applicable payer reimbursement must be applied to the account before an application for Financial Assistance will be considered. It is the responsibility of the applicant to follow-up on any of these sources of payment. E. All applications for assistance will be completed by the Customer Service Center, Patient Access Services or department contacts listed below.