Insurance & Financial Support

Uncompensated Care Program

1. Objective: To establish operational guidelines to 1) identify uninsured patients who are financially or medically indigent that may qualify for uncompensated/charity (free) care or financial assistance, to process patient applications for uncompensated/charity care or financial assistance and 2) to bill and collect from uninsured patients, including those who quality as financially or medically indigent under this policy.


2. Scope:
   All DMC Hospitals,
   Applies to facility charges only, professional charges are excluded.
   All Services must be medically necessary as determined by the patient’s physician.

POLICY:

1. Uncompensated/Charity Care or Financial Assistance. The DMC hospitals shall provide uncompensated/charity care (free care) or financial assistance to uninsured patients who qualify or are classified as financially or medically indigent for medically necessary services in accordance with the Uncompensated/Charity Care Financial Assistance process set forth below.
   • Financially Indigent 100% discounts shall be available for uninsured patients with income below 200% of the Federal Poverty Level
   • Medically Indigent – Non Catastrophic 40% – 80% discounts are available for uninsured/underinsured patients either with
     (1) income greater than 200% of Federal Poverty Level or less than 500% of Federal Poverty Level or
     (2) with outstanding balances for hospital (facility) services in excess of 50% of their annual income.
   • Medically Indigent Catastrophic 40% - 80% discounts are available for uninsured underinsured patient with income in excess of 500% Federal Poverty guidelines if outstanding hospital balances is greater than 50% of the patients annual income.
See attached Financial Assistance Eligibility Guidelines.


2. Billing and Collection Processes for Uninsured Patient. All uninsured patients receiving care at the DMC will be treated with respect and in a professional manner before, during and after receiving care.

Debt Collection Policy

Read more about the DMC Debt Collection Policy.

PROCEDURE:

1. CHARITY CARE AND FINANCIAL ASSISTANCE PROCESS
   1. Application. Each patient applying for uncompensated/charity care financial assistance must complete a Financial Assistance Application Form (Assistance Application). An example Financial Assistance Application is attached. The Application allows for the collection of information needed to determine eligibility for financial assistance.
      1. Calculation of Immediate Family Members. Each Hospital will request that patients requesting charity care verify the number of people in the patient’s household.
         1. Adults. In calculating the number of people in an adult patient’s household, Hospital will include the patient, the patient’s spouse and any dependents of the patient or the patient’s spouse.
         2. Minors. For persons under the age of 18. In calculating the number of people in minor patient’s household, Hospital will include the patient, the patient’s mother, dependents of the patient’s mother, the patient’s father, and dependents of the patient’s father.
      
      
      2. Calculation of Income.
         1. Adults. For adults, determine the sum of the total yearly gross income of the patient and the patient’s spouse (the “Income”). Hospital may consider other financial assets of the patient and the patient’s family (members of family are as defined in section “Calculation of Immediate Family Members”) and the patient’s or the patient’s family’s ability to pay.
         2. Minors. If the patient is a minor, determine the Income from the patient, the patient’s mother and the patient’s father. Hospital may consider other financial assets of the patient and the patient’s family (members of family as defined section “Calculation of Immediate Family Members”) and the patient’s or the patient’s family’s ability to pay.
   2. Income Verification. Each Hospital shall request the patient to verify Income and provide the documentation requested in the Financial Assistance Application. NOTE: Tax Returns and W-2’s should be collected for year prior to date of admission.
      1. Documentation Verifying Income. Income may be verified through any of the following mechanisms:
         • Tax Returns (Hospital preferred income verification document)
         • IRS Form W-2
         • Wage and Earnings Statement
         • Pay Check Remittance
         • Social Security
         • Worker’s Compensation or Unemployment Compensation Determination Letters
         • Qualification within the preceding 6 months for governmental assistance program (including food stamps, CDIC, Medicaid and AFDC)
         • Telephone verification by patient’s employer of the patient’s Income
         • Bank statements, which indicate payroll deposits
      2. Documentation Unavailable. In cases where the patient is unable to provide documentation verifying Income, the Hospital may at it’s sole discretion verify the patient’s Income in either of the following two ways:
         1. By having the patient sign the Financial Assistance Application attesting to the veracity of the Income information provided or
         2. Through the written attestation of the Hospital personnel completing the Financial Assistance Application that the patient verbally verified Hospital’s calculation of Income.
      
      
      3. Expired Patients. Expired patients may be deemed to have no Income for purposes of the Hospital’s calculation of Income. Documentation of Income is not required for expired patients. Income verification is still required for any other family members (members of family are as defined in section “Calculation of Immediate Family Members”).
      
      
      4. Homeless Patients. Homeless patients may be deemed to have no Income for purposes of the Hospital’s calculation of Income. Documentation of Income is not required for homeless patients. Income verification is still required for any other family members (members of family are as defined in section “Calculation of Immediate Family Members”) only if other family information is available.
      
      
      5. Incarcerated Patients. Incarcerated patients (incarceration verification should be attempted by Hospital personnel) may be deemed to have no Income for purposes of the Hospital’s calculation of Income, but only if their medical expenses are not covered by the governmental entity incarcerating them (i.e. the Federal Government, the State of or a County is responsible for the care) since in such event they are not uninsured patients. Income verification is still required for any other family members (members of family are as defined in section “Calculation of Immediate Family Members”).
      
      
      6. International Patients. International patients who are uninsured and whose visit to the Hospital was unscheduled will be deemed to have no Income for purposes of the Hospital’s calculation of Income. Income verification is, moreover, still required for any other family members (members of family are as defined in section “Calculation of Immediate Family Members”) only if other family are United States citizens.
      
      
      7. Eligibility Cannot be Determined. If and when Hospital personnel cannot clearly determine eligibility, the Hospital personnel will use best judgment and submit a memorandum (such memorandum should be the first sheet in the documentation packet) listing reasons for judgment along with Financial Assistance documentation to appropriate supervisor. The Hospital Supervisor will then review the memorandum and documentation. If the Supervisor agrees to approve the eligibility, they will sign Eligibility Determination form and continue with normal Approval process. If the Supervisor does not approve eligibility of the patient under this Policy, the Supervisor should sign the submitted memorandum and return all documentation to Hospital personnel who will note account and scan documentation into IDOC. If Supervisor disagrees with hospital personnel’s judgment, Supervisor should state reasons for new judgment and will return documentation to hospital personnel who will follow either denial process or approval process as determined by Supervisor.
      
      
      8. Classification Pending Income Verification. During the Income Verification process, while Hospital is collecting the information necessary to determine a patient’s Income, the patient may be treated as a self-pay patient in accordance with Hospital policies.
      
      
   3. Information Falsification. Falsification of information may result in denial of Financial Assistance Application. If, after a patient is granted financial assistance as either Financially Indigent or Medically Indigent, and Hospital finds material provision(s) of the Financial Assistance Application to be untrue, the financial assistance may be withdrawn.
   
   
   4. Request for Additional Information. If adequate documents are not provided, Hospital will contact the patient and request additional information. If the patient does not comply with the request within 14 calendar days from the date of the request, such non-compliance will be considered an automatic denial for financial assistance. A note will be input into Hospital computer system and any and all paperwork that was completed will be scanned into IDOC. No further actions will be taken by Hospital personnel. If requested documentation is later obtained, all filed documentation will be pulled and patient will be reconsidered for Financial Assistance.
   
   
   5. Automatic Classification as Financially Indigent. The following is a listing of types of accounts where Financial Assistance is considered to be automatic and documentation of Income or a Financial Assistance application is not needed.
      • • Medicare accounts-Exhausted Days/Benefits
        • Medicaid spend down accounts
        • Medicaid or Medicare Dental denials
        • Medicare Replacement accounts with Medicaid as secondary-where Medicare Replacement plan left patient with responsibility
        • Adult Benefit Waiver Enrollees
      1. Adult Benefit Waiver Program. It will be unnecessary to complete a Financial Assistance/Application for ABW enrollees.
         
         Required Documentation: Complete the financial assistance eligibility determination only attach a copy of the State of Michigan Eligibility verifying the patient’s enrollment in Adult Benefit Waiver Program, obtain the appropriate signatures for approval.
      
      
   6. Classification as Financially Indigent. Financially Indigent is defined an uninsured person who is accepted for care with no obligation (charity care) or with a discounted obligation to pay for the services rendered based on the Hospital Eligibility Criteria.
      1. Classification. The Hospital may classify as Financially Indigent all uninsured patients whose income, as determined in accordance with the Financial Assistance Application, is less than or equal to 200% of the poverty guidelines updated annually in the Federal Register by the U.S. Department of Health and Human Services (Federal Poverty Guidelines).
      
      
      2. Acceptance. If Hospital accepts the patient as Financially Indigent, the patient may be granted charity care or financial assistance discounts in accordance with the attached Financial Assistance Eligibility Guidelines.
      
      
   7. Classification as Medically Indigent – Non Catastrophic. Medically Indigent Non-Catastrophic is defined an uninsured or underinsured patient who is accepted for care with a discounted obligation to pay for services rendered based on the Hospital Eligibility Criteria.
      1. Classification. The Hospital may classify as Non-Catastrophic Medically Indigent all uninsured/under-insured patients whose income, as determined in accordance with the Financial Assistance Application is be between 200% - 500% of the Federal Poverty Guidelines updated annually in the Federal Register by the U.S. Department of Health and Human Services.
      
      
      2. Acceptance. If Hospital accepts the patient as Medically Indigent Non Catastrophic, the patient maybe granted financial discounts in accordance with the attached Financial Assistance Eligibility Guidelines.
      
      
   8. Classification as Medically Indigent – Catastrophic. Medically Indigent Catastrophic is defined uninsured/underinsured patient who does not quality as Financially Indigent under this policy because the patient’s Income exceeds 500% of Federal Poverty Guidelines, but whose medical or hospital bills exceed a specified percentage of the person’s Income, and who is unable to pay the remaining bill.
      1. Initial Assessment. To be considered for classification as a Medically Indigent Catastrophic patient, the amount owed by the patient on all outstanding accounts after all payments by the patient must exceed 10% of the patient’s Income and the patient must be unable to pay the remaining bill. If the patient does not meet the Initial Assessment criteria, the patient may not be classified as Medically Indigent Catastrophic.
      
      
      2. Acceptance The Hospital may also accept a patient as Medically Indigent when they meet the acceptance criteria set forth below.
         • 1. The patient’s bill is greater than 50% of the patient’s Income, calculated in accordance with the Hospital’s income verification procedures, and the patient’s Income is greater than 500% of the Federal Poverty Guidelines. The Hospital will determine the amount of financial assistance granted to these patient’s in accordance with the attached Financial Assistance Eligibility Guidelines.
   
   
   9. Approval Procedure. Hospital will complete a Financial Assistance Eligibility Determination Form for each patient granted status as Financially Indigent or Medically Indigent. The approval signature process is as following:
      • • $1 - $2,000 Director
        • $2,001 - $10,000 Director and CFO
        • $10,001 and above Director, CFO and CEO (or CEO’s Designee)
      1. The Eligibility Determination Form allows for the documentation of the administrative review and approval process utilized by the Hospital to grant financial assistance. Any change in the Eligibility Determination Form must be approved by the Vice President of Patient Financial Services. If application is approved, approval is automatic for all admissions for calendar year on balances that can be considered for Financial Assistance.
   
   
   10. Denial for Financial Assistance. If the Hospital determines that the patient is not Financially Indigent or Medically Indigent under this policy, it shall notify the patient of this denial in writing. A suggested denial of coverage letter is attached to this policy.
   
   
   11. Document Retention Procedures. Hospital will maintain documentation sufficient to identify for each patient qualified as Financially Indigent or Medically Indigent, the patient’s Income, the method used to verify the patient’s Income, the amount owed by the patient, and the person who approved granting the patient status as Financially Indigent or Medically Indigent. All documentation will be scanned into document imaging system (IDOC). The accounts will be scanned into IDOC according to the date the Financial Assistance adjustment was entered onto the account. All Financial Assistance applications and all documentation will be retained online for 7 years.
   
   
   12. Reservation of Rights. It is the policy of the Hospitals to reserve the right to limit or deny financial assistance at the sole discretion of each of its Hospitals.
   
   
   13. Non-Covered Services. Non-medically necessary services balances associated with routine co-pay and deductibles unless hardship can be demonstrated.


2. BILLING AND COLLECTION PRACTICIES FOR ALL UNINSURED PATIENTS, INCUDING THOSE WHO QUALIFY AS FINANCIALLY INDIGENT OR MEDICALLY INDIGENT UNDER THIS POLICY
   1. Fair and Respectful Treatment. Uninsured patients will be treated fairly and with respect during and after treatment, regardless of their ability to pay.
   
   
   2. Financial Counseling. All uninsured patients will be provided with financial counseling, including assistance applying for state and federal health care programs such as Medicare and Medicaid. If not eligible for governmental assistance, uninsured patients will be informed of and assisted in applying for charity care and financial assistance under the hospital’s charity care and financial assistance policy. Hospital representative will attempt to meet with all uninsured patients prior to discharge from Hospital. Hospitals should ensure that appropriate staff members are knowledgeable about the existence of the hospital’s financial assistance policies. Training should be provided to staff members (i.e., billing office, financial department, etc.) who directly interact with patients regarding their hospital bills.
   
   
   3. Additional Invoice Statement or Enclosures. When sending a bill to uninsured patients, the Hospital should include (a) a statement on the bill or in an enclosure to the bill that indicates that if the patient meets certain income requirements, the patient may be eligible for a government- sponsored program or for financial assistance from the Hospital under its charity care or financial assistance policy; and (b) a statement on the bill or in an enclosure to the bill that provides the patient a telephone number of a hospital employee or office from whom or which the patient may obtain information about such financial assistance policy for patients and how to apply for such assistance. The following statement on the bill or in an enclosure to the bill complies with the above requirement of the Section B.3.:
      “Please note, based on your household income, you may be eligible for Medicaid or financial assistance from the Hospital. For further information, please contact our customer service department at (888) 233-7868.”
   
   
   4. Notices. Each of the DMC hospitals will post notices regarding the availability of financial assistance to uninsured patients. These notices should be posted in visible locations throughout the hospital such as admitting/registration, billing office and emergency department. The notices also should include a contact telephone number that a patient or family member can call for more information.
   
   
   5. Liens and Primary Residences. The Company’s hospitals shall not, in dealing with patients who quality as Financially Indigent or Medically Indigent under this Policy, place or foreclose liens on primary residences as a means of collecting unpaid hospital bills. However, as to those patients who qualify as Medically Indigent but have income in excess 500% of the Federal Poverty Guidelines, the Company may place liens on primary residences as a means of collecting discounted hospital bills, but the Company’s hospital may not pursue foreclosure actions in respect of such liens.
   
   
   6. Garnishments. The Company’s hospitals shall only use garnishments on Medically Indigent Patients where clearly legal under state law and only where it has evidence that the Medically Indigent Patient has sufficient income or assets to pay his/her discounted bill.
   
   
   7. Collection Actions Against Uninsured Patients. Each of the Company’s hospitals should have written policies outlining when and under whose authority an unpaid balance of any uninsured patient is advanced to collection, and hospitals should use their best efforts to ensure that patient accounts for all uninsured patients are processed fairly and consistently.
   
   
   8. Interest Free, Extended Payment Plans. All uninsured patients shall be offered extended payment plans by the Company’s hospitals to assist the patients in settling past due outstanding hospital bills. The Company’s hospitals will not charge uninsured patients any interest under such extended payment plans.
   
   
   9. Body Attachments. The Company’s hospitals will not use body attachment to require that is uninsured patients or responsible party appear in court.
   
   
   10. Collection Agencies Follow Hospital Collection Policies. The Company’s hospitals should define the standards and scope of practices to be used by their outside (non-hospital) collection agencies, and should obtain written agreements from such agencies that they will adhere to such standards and scope of practices. These standards and practices should not be inconsistent with the Company’s collection practices for its hospitals set forth in this Policy.


3. RESERVATION OF RIGHTS AGAINST THIRD PARTIES.
   Nothing in this Policy shall preclude the Company’s hospitals from pursuing reimbursement from third party payors, third party liability settlements or tortfeasors or other legally responsible third parties.

REFERENCES

Charity Care, Financial Assistance and Billing and Collection Policies for Uninsured Patients
Reference Number: PFS00.1001