Purpose

To establish a policy and procedure and to provide guidelines to identify patients who potentially qualify for write-offs of co-payments/deductibles due to their financial status and inability to pay for medically necessary care and treatment.

Policy

It is the policy of the practice that co-payments and deductible amounts relating to payment for services shall be collected to the full extent required by Federal and state laws and private payor agreements. The practice does not allow routine waiver of insurance co-payments and deductibles under any circumstances. In limited circumstances, patients may qualify for a financial hardship discount.

The practice recognizes that a patient’s economic situation may be such that paying co-payments, deductibles and/or co-insurance would create a financial hardship by impacting the patient’s ability to pay for necessary living expenses. The practice has consequently developed a policy to determine through financial screening those patients who are financially unable to pay for their care. This policy distinguishes between a “bad debt” patient (one who is unwilling to pay) and an indigent patient (one who is unable to pay).

This policy identifies the circumstances under which the practice will waive the obligation of a patient whose financial status makes it inordinately difficult, or impossible, to pay for necessarily medical services. The evaluation of the necessity for medical treatment will be based upon the clinical judgment of the medical provider regardless of the financial status of the patient. The clinical judgment of the patient’s physician will be the sole determining criterion for determining whether the services are medically necessary.

Financial hardship will be determined in accordance with this policy and based upon the US Department of Health and Human Services Poverty Guidelines. The percentage discount will vary based on the patient’s income level.

Procedure

All unfunded patients, unable to pay required deposits, co-payments or deductibles, will where practicable be financially screened prior to the time that services are provided. Funded patients covered by any governmental or commercial third party payer, who claim an inability to pay their share of costs due to economic hardship, may be screened at a later time.

The financial screening process will determine eligibility for a write-off under this policy. However, in certain cases, additional extenuating circumstances may exist which would allow special consideration for approving a write-off for a patient who does not meet the established criteria. Such extenuating circumstances include, but may not be limited to:

1. The amount owed by the patient in relation to his/her total means.
2. The medical status of the patient or of the primary wage earner in the household.
3. The employment potential of the patient in light of his/her skills and age in relationship to the job market.
4. The likely emotional and medical impact of the financial indebtedness on the patient and family.
5. The patient’s willingness to work with the practice in assisting to exhaust all other payment resources.
6. Whether the patient lives on a fixed income. The ultimate approval or denial of a write-off in these cases shall be the responsibility of the underwriter.

The following procedure shall apply to the determination of whether any deposits, co-payments or deductibles will be discounted or written-off pursuant to this policy:

1. The total family/household income will be compared to the Federal Poverty Guidelines. Any patient whose annual household income falls within 600% of the Federal Poverty Guidelines will be considered a candidate for a write-off under this policy.
2. Patients whose annual household income is within 300% of the Federal Poverty Guidelines will be eligible for a write-off of all deposits, co-payments or deductibles.
3. Patients whose annual household income is greater than 300% of the Federal Poverty Guidelines but less than or equal to 600% may be eligible for a write-off if they can demonstrate their annual medical expenses exceeded 30% of their income in the most recent 12-month period.
4. When a patient has been determined to qualify for a write-off under this policy, the following documentation must be obtained:
5. A copy of a completed Financial Hardship Disclosure Form. (Whenever possible, supporting documentation should be included, such as a prior year tax return, W-2 form, recent check stub, etc.)
6. Copies of any additional documentation which outlines any extenuating circumstances that may have been considered in the determination of eligibility for a write-off under this policy.

FINANCIAL ASSISTANCE

Our practice is dedicated to providing quality health care to our patients. We realize that payment of those service may be a financial hardship for you at this time. We are consequently offering you the opportunity to apply for financial assistance.

The following is a Disclosure Form that demonstrates your financial condition. You must complete this document in full to receive consideration for our financial assistance program. If your financial situation meets the criteria established by your practice, part or all of your account balance may be forgiven.

In order to process your application, we need the following:

• The Disclosure Form completed in its entirety
• Proof of income (e.g., at least three pay stubs for any wage earner contributing to household income, unemployment, public assistance, etc.)
• Copy of your most recent 1040 tax return, including applicable schedules
• If your most recent tax return is not available, then we need either a Social Security Awards Letter or proof of non-filing from the IRS

We realize that your income from previous tax records may not reflect your current circumstances. If so, please attached a brief note that describes your current financial situation.

Please note that additional information may be requested if needed to assist in making a determination. Once we have reviewed your Disclosure Form, we will notify you of our decision in writing.

FINANCIAL ASSISTANCE DISCLOSURE FORM

Because of my financial condition, it would be extremely difficult for me to pay the co-payment and/or deductible for the medical services which are being rendered to me without seriously affecting my ability to pay for other necessary living expenses.

I certify that the information provided in this Disclosure Form is true and correct.