Vail Valley Medical Center & VVMC-Diversified Services Guideline Title: Status: Financial Assistance Guideline Final Effective: 10/01/2012 Replaced: 8241.09, PFS100 Financial Assistance Program/Charity Care, Sliding Fee Scale Financial Counseling Program, HELP, and untitled guidelines/policies. Purpose: This guideline establishes the financial requirements for payment of services based on consistent compliance criteria incorporating individual patient financial conditions and circumstances. To ensure the appropriate resolution of patient financial obligations while maintaining optimal customer satisfaction and commitment to providing medically necessary services to all patients regardless of their ability to pay. Medical Necessity may be determined by certain payers resulting in patient responsibility for services rendered. To ensure that all patients are given consistent payment options and that patient liability balances are paid in a timely manner. Definitions: 1. Non-Emergency Patients: An Emergency Medical Condition has not been identified. Non-Emergency Patients are expected to resolve their identified financial obligations prior to their scheduled date and time of service. Financial arrangements are expected prior to services being rendered. If the patient does not resolve the account(s) as defined within the financial assistance guidelines, the service request may be clinically reviewed for delay, and rescheduled or cancelled as appropriate. 2. Emergency Patients: An Emergency Medical Condition has been identified. Emergency services (regardless of the patient s ability to pay for those services) will be performed in compliance with applicable Federal and State regulations when an Emergency Medical Condition has been identified. 3. Emergency Medical Condition as defined by EMTALA: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part (or, with respect to a pregnant woman who is having contractions that there is inadequate time to effect a safe transfer to another hospital before delivery, or that the transfer may pose a threat to the health or safety of the woman or her unborn child). Page 1 of 6
4. Clinical Review: A comprehensive review performed by a licensed clinician, of the patient s medical history to determine urgency of services. 5. Financial Review: A comprehensive review performed by the Vail Health System Designee, of past payment history, current ability to pay, and future liabilities. 6. Case Review: A collective review comprised of a Clinical Review and a Financial Review. 7. Household/Family Income: A combination of earned income and unearned income that includes, but is not limited to: wages, salaries, tips, food stamps and other taxable employee pay, Union strike benefits, Long-term disability benefits received prior to minimum retirement age, Net earnings from self-employment if you own or operate a business, or you are a minister or member of a religious order, gross income received as a statutory employee, Interest and dividends, Retirement Income, Social security, Unemployment benefits, Alimony, and Child support. The organization does not further define the terms household or family, due to the considerable variations of their interpretation. A determination will be made on a case by case basis. Procedures: A. PATIENT SEEKING FINANCIAL COUNSELING SERVICES: 1. Hospital Services and Clinic Services documentation requested for qualification: i. Government issued photo identification card. ii. United States issued Social Security ID card for hospital services only. iii. Proof of patient s legal residence in Eagle County, Colorado, for past 6 consecutive months from application date. Examples include, but are not limited to: a) Current Mortgage Agreement. b) Current Lease agreement. c) Notarized letter from the applicant s landlord. iv. Household/family s income. Examples include, but are not limited to: a) Two full months of pay stubs from each employer or notarized letter from each employer or documentation of government unemployment support (SSI or other) b) Two years of income taxes or IRS non-filing transcripts (required for Hospital Services). v. Declaration of assets a) Two months of checking and/or savings account statements. b) Other assets. Examples include, but are not limited to: a. Retirement benefits. b. Stocks and/or bonds. c. Certificates of deposit. vi. Documentation of expenses a) Utilities. b) Credit card or other debt. c) Other fixed expenses. vii. Number of persons dependent on household/family income. viii. Proof of Household/family incomes up to 250% of the Federal Poverty Guidelines published in the Federal Register (see chart below). 2. Hospital Services (Vail Valley Medical Center) i. Qualification of Patients: a) Legal presence in the United States of America. b) Residents of Eagle County for past 6 consecutive months are eligible for hospital services. Page 2 of 6
c) Residents of Lake, Summit, Moffat, Pitkin, Routt, and Grand Counties are eligible for VVMC services related to cancer treatment services only. d) Patient does not currently qualify for a government insurance product. e) Cosmetic procedures are not covered under financial assistance. f) Patient balances categorized as non-covered services. ii. Application Process Requirements: a) Initial counseling session with a Financial Counselor. b) Successful completion and submission of the application with required documentation within 10 business days of receipt of application. c) Federal Poverty Guidelines A through H apply for hospital services. 3. Clinic Services (VVMC Diversified Services Clinics) i. Qualification of Patients: a) Residents of Eagle County for past 6 consecutive months are eligible for clinic services. b) Patient does not currently qualify for a government insurance product. c) Cosmetic procedures are not covered under financial assistance. d) Eagle Care Clinic patients may not qualify or have commercial insurance products. e) All grants will be administered within the policies and standards of the clinic. ii. Application Process Requirements: a) Initial counseling session with a Financial Counselor. b) Successful completion and submission of the application with required documentation within 10 business days of receipt of application. c) Federal Poverty Guidelines Rates D through H applies for clinic services. B. TERM AND TERMINATION OF FINANCIAL ASSISTANCE 1. Clinical services approval term will be determined upon review of application. 2. Hospital services are approved per episode. 3. A patient must apply for financial assistance within 3 months of the episode, clinic appointment, or visit. 4. Patient with Medicaid applications pending acceptance may be screened for financial assistance though full application process will not commence until such time as a program denial document can be presented. 5. Financial assistance applications and all supporting documents will be held on file for no less than 10 years. 6. Random audits shall be conducted not less than annually to ensure compliance. 7. Any account balance that is in bad debt status will not be eligible for consideration under the financial assistance program. 8. Patients participating in the financial assistance program who miss two consecutive payments may be referred to collections. C. THRESHOLD DETERMINATION: Threshold processing is determined according to the type of service, anticipated charge and/or if the service is known to have restricted coverage based on completing comprehensive processing activities. The following service classifications meet threshold guidelines for comprehensive processing: i. Inpatients ii. Surgical patients iii. Observation patients iv. Outpatient services 1. Only after the medical screening examination has been completed and the patient has been stabilized, calls will be initiated to third party payers to verify insurance coverage and for notification of the patient s arrival in the emergency setting. Emergency cases having been stabilized or having completed treatment will be required to finalize financial obligations prior to discharge. Page 3 of 6
Patients admitted to stabilize their condition without meeting financial resolution requirements, will be identified and monitored post stabilization for resolution prior to discharge. 2. All patients meeting established threshold guidelines will undergo comprehensive access processing including pre-registration/registration, insurance verification, authorization of service (i.e. precertification, compliance screening, medical necessity review etc.), managed care requirement resolution, estimation of patient and third party liabilities, financial education, financial assistance reviews, financial commitment to resolve the outstanding balance, and case review as applicable. Coordination of benefits will be determined during the comprehensive processing for all patients including, but not limited to, clinical trials, experimental and research participants. Comprehensive processing will be completed for all scheduled patients prior to their scheduled date and time of service. For non-scheduled threshold patients including emergency patients who have been stabilized, comprehensive access processing will be completed at the earliest opportunity. 3. Patients determined not to meet established threshold guidelines will undergo limited access processing including pre-registration/registration, local medical review when required to determine medical necessity, electronic or automated insurance verification, authorization of service (i.e. precertification, compliance screening, etc.), financial assistance reviews and financial resolution of identified patient co-payment amounts. For scheduled patients meeting threshold guidelines, processing will be completed prior to the scheduled date and time for service. For non-scheduled patients, including emergency patients who have been stabilized, under threshold access processing will be completed at the earliest opportunity. D. PATIENTS WITH VALID INSURANCE COVERAGE: The processing of all identified insurance claim submission activities for billing and payment will be performed according to the following guidelines: 1. Insurance will be accepted as satisfying a patient s requirement for financial resolution as part of comprehensive processing when all required insurance data set information has been collected/validated/updated and coverage is verified. Insurance accounts with anticipated deductibles, co-payments and non-covered charges will be screened and processed as follows: i. Insurance accounts with deductibles, co-payments, and non-covered charges identified during pre-services or time of service will be flagged for financial resolution of these balances. Based on case review, services may be delayed or canceled pending preservice and/or time of service payment to create financial resolution. For emergency patients, identified co-payments will be requested only after treatment has been completed and/or the patient has been stabilized. ii. Insurance accounts where patient liabilities cannot be identified until after insurance processing will become a patient liability and will be processed according to patient liability billing and follow-up guidelines. For accounts meeting threshold guidelines and patient liability cannot be established during insurance processing, a down payment may be requested. iii. Insurance accounts with identified patient liabilities will be required to financially resolve identified amounts using the payment options no later then discharge. Payment options may include, but not be limited to: a) Cash, money orders, or checks b) Credit Cards: VISA, MasterCard, Discover, and American Express c) Payment plans 2. Insurance beyond CHP+, Medicare, and Medicaid will not be accepted by Eagle Care Medical Clinic, a Diversified Services Clinic. E. PATIENTS IDENTIFIED AS SELF PAY: When the patient has no insurance coverage, the account will be documented as the responsibility of the patient/guarantor and processed according to the following guidelines: 1. All patients identified as self pay and aforementioned established thresholds may be screened for Medicaid eligibility and Financial Assistance. i. Accounts will be evaluated for Medicaid coverage and will also be evaluated for possible Financial Assistance qualification. Page 4 of 6
2. Upon completion of patient financial counseling, patients are required to finalize an acceptable financial agreement. 3. If the patient is unable to pay their anticipated balance in full prior to service: i. For hospital services, patients may be asked to make a 50% deposit on the anticipated patient liability and establish monthly payments. ii. If the patient is unable to make a 50% deposit prior to services being rendered, the patient s case may be reviewed by management. iii. Diversified Services Clinic patients may be asked to make a minimum deposit (amount determined per episode). The remaining balance due will be collected upon patient checkout. F. PATIENTS IDENTIFIED AS RESIDING OUTSIDE OF THE COUNTRY: When the patient is not a resident of the United States of America and has a permanent address outside of the country: 1. During the admission process, an Admissions Representative may ask the patient how they will be paying for the service. 2. If the provided insurance card has an address in the United States, the insurance information will be collected. All co-pays, coinsurance, and deductibles will be collected. 3. If provided insurance card does not have a United States address, the account will be entered as self pay and all charges will be the responsibility of the patient/guarantor. 4. Non-Emergent scheduled services may require a deposit equal to 50% of total anticipated liability which is due 48 hours prior to the services being performed. 5. For Emergent services, an Admissions Representative will attempt to collect all co-payments, coinsurance, and deductibles applicable based on Federal and State regulations when an Emergency Medical Condition has been identified. Page 5 of 6
2014 Federal Poverty Guidelines Persons in family/household Up to 250% FPG 1 29,175 2 39,325 3 49,475 4 59,625 5 69,775 6 79,925 7 90,075 8 100,225 For families/households with more than 8 persons, add $4,060 for each additional person. 2014 Sliding Fee Discount Scale: Based on 250% of Federal Poverty Guidelines Federal Poverty Guidelines Rate Patient Owes Adjustment 100% - 109% Rate A 0% 100% 110% - 129% Rate B 10% 90% 130% - 149% Rate C 20% 80% 150% - 169% Rate D 30% 70% 170% - 189% Rate E 40% 60% 190% - 209% Rate F 50% 50% 210% - 229% Rate G 60% 40% 230% - 250% Rate H 70% 30% Reviewed and Approved By: Patient Accounts, Admissions, Insurance Verification, Diversified Services, Risk, Compliance, CFO, Patient Safety Council Content Owner: References: Management representatives from Revenue Cycle Services and VVMC Diversified Services Federal Register, EMTALA Page 6 of 6