Portland Service Area
Hospital
Financial Assistance Guidelines
A Well-Considered Response to Community
Health Need
Prepared by:
Oregon Health Action Campaign
Submitted to:
Tri-County Communities in Charge
Multnomah County Health Department
1120 SW 5th, 14th
floor, Portland, OR 97204
(503) 988-3674
DRAFT: 02-15-02
Table of Contents:
|
Executive
Summary |
iii |
|
Acknowledgements |
iv |
|
Financial
Assistance Agreement – Portland Service Area Hospitals.
(Note: In a
March 15th, 2001 letter, the Oregon Association of
Hospitals and Health Systems – OAHHS - encouraged its affiliated
hospitals to “seriously consider” implementing the uniform financial
assistance policies and procedures developed by the Portland are
hospitals in a process facilitated by OAHHS). |
v |
|
Chronology of
Events |
vi |
|
Community
Benefits: Need and Historical Context |
1 |
|
Evaluating the
availability of charity care information: Community Based Research
Research
Methodology
Summary of
Findings
Implications of
findings |
2 |
|
Next Steps |
4 |
|
Appendix
1. OHAC
Director's Statement |
6 |
|
2. Portland
Service Area Hospital Financial Assistance Task Force Report |
7 |
|
3. Safety Net
Application |
25 |
|
4. Press
Coverage (inserts) |
26 |
|
5. Financial
Assistance Brochure (inserts) |
27 |
EXECUTIVE SUMMARY
In November 2000, after several
months of meetings, in a process facilitated by Oregon Association of
Hospitals and Health Systems (OAHHS) Portland Service Area Hospitals
completed the development of uniform financial assistance policies and
procedures. Key components of their agreement included:
§
100% assistance for families
at or below 150% Federal Poverty Level. Partial assistance for families
between 150-200% of FPL. Case-by-case consideration of assistance for
families above 200% FPG.
§
Financial application and
materials written in at least four most frequently used languages at grade
school reading level.
§
Published communications such
as signs, business cards, in key access points specifically: emergency
rooms, admitting, business/ patient account offices, urgent care centers.
Notification of assistance on every bill sent to patients (when technically
possible).
§
Brochure available to public
that explains the Financial Assistance process in user-friendly
terminology. Information about assistance available during registration
process. If a person's situation changes, they can reapply for assistance.
§
Standardized application
process in Portland area.
In March 2001, the
Oregon Association of Hospitals and Health Systems encouraged all of its
affiliates to seriously consider adopting the policies and procedures
developed during the Portland area process. Several had already done so.
Portland area
hospital financial assistance policies and procedures have been in place for
one year. Throughout the year, representatives of Portland’s health safety
net, the Oregon Health Action Campaign, Tri County Communities in Charge and
the Portland service area hospitals have continued to meet to discuss
successes, challenges, and components of an evaluation of financial
assistance policy implementation.
This document
describes the chronology of events leading up to the Portland area
agreement; the historical and legal framework for provision of charity care
/ community benefits; components of the consumer research that highlighted
the problems with patient access to information about charity care /
financial assistance; and steps that must still be taken to ensure that all
those eligible can learn about and take advantage of the opportunity to
apply for financial assistance.
It has been compiled in
hopes that it may provide guidance to other health institutions and health
advocacy organizations struggling with ways to provide universal and
affordable access to some level of health services in the long dawning of
the systemic and policy reform necessary to bring about universal coverage.
Acknowledgements
Our work and success would not have been
possible without the financial and / or personal / professional support from
the following organizations and individuals:
Coalition of Community Health Clinics
Community Catalyst
Kaiser Permanente
Legacy Health System
Multnomah County Health Department
Neighborhood Health Clinics
Oregon Association of Hospitals and Health
Systems
Oregon Health Action Campaign
Oregon Primary Care Association
Providence Health System
Salem Hospital
Tri County Communities in Charge
Wallace Medical Concern
Northwest Health Foundation
Public Welfare Foundation
Robert Wood Johnson Foundation
Surdna
Kent Ballentyne
Ric Burger
John Lee
Dennis Noonan
Colleen Russell
Ken Rutledge
Terry Smith
Michael Sorensen
Teresa Spalding
Barney Speight
Steve Weiss
About the key participating organizations
Coalition of Community Health Clinics:
A network of private, non-profit community clinics in the Portland
Metropolitan area that provide primary health care services to people who
have no access to mainstream healthcare. Clinics represent a large portion
of the urban “safety net”, assuring quality primary health care services to
those unable to receive them in traditional medical settings.
Oregon Association of Hospitals and Health
Systems
OAHHS MISSION
Oregon Association of Hospitals and Health
Systems is a statewide association
dedicated to providing representation,
advocacy and assistance for hospitals
and healthcare systems. The association,
through leadership and collaboration
among healthcare providers, promotes quality
healthcare that is adequately
financed and universally accessible.
Oregon Health Action Campaign (OHAC):
a coalition of individuals and organizations committed to empowering the
consumer voice in the development of health systems that give all people
access to the care they need, when they need it, from providers of their
choice at an affordable cost. OHAC houses the Mergers, Acquisitions and
Community Benefits Taskforces, and the Portland and Marion/Polk County
Community Benefits Taskforces.
Tri-County Communities in Charge
The Tri-County Communities in
Charge (TCCIC) initiative is a local initiative with focus on health care
access for all within the Portland Metropolitan region. This initiative has
built on a community consensus around two themes that serve as the
foundation for the community's approach to care for the uninsured. The two
themes are:
1.
Refine and restructure the safety net system to utilize existing
resources with greater efficiency and effectiveness; and
2.
Increase access for defined populations and sub-populations through
well-planned investment of resources for system expansion.
The Tri-County Communities in Charge
initiative emphasizes a process that will develop the existing health care
safety net into a well functioning and integrated system of care for the
uninsured. The three major components employed to accomplish these tasks
include:
-
A Safety Net Authority to organize
and govern the safety net system.
-
An Outreach and Education Program to
promote of the safety net and other resources
-
A Uniform Charity Care Policy to be
implemented by local hospitals
Chronology of Events
1994 – 1998:
Numbers of people call Oregon Health Action Campaign (OHAC) offices to ask
for help in paying past due hospital bills or describing being sent to
collections by hospitals.
Spring and summer 1999:
OHAC recruits, trains and dispatches volunteers to research the availability
of charity care policies and interpretation services in Marion and Polk
County hospitals. Bankruptcy records and lien filings also researched.
December 1999:
OHAC meets with Salem Hospital to discuss results of research and resulting
report to be released by end of January, 2000. Meeting participants include
people who have been sent to collections or been forced into bankruptcy by
hospital collection practices; the CEO, CFO and various staff from Salem
Hospital; and representatives from OHAC and Salem area ecumenical, labor and
elder organizations.
Mid – December 1999:
Dennis Noonan, CEO Salem Hospital, convenes meeting which includes
representatives of the three other Marion Polk County Hospitals and the same
people who were part of the first December meeting.
January 2000:
Marion and Polk county hospitals agree to adopt and implement uniform
charity care policies and procedures and to participate in March, 2000
community forum on unmet health need.
February 2nd, 2000:
Meetings with the press, Marion and Polk County hospitals and OHAC to
present financial assistance procedures and report that triggered their
development.
February and March 2000:
Research process initiated and completed in Portland metropolitan area.
July 2000:
OHAC’s Ellen Pinney invited to OAHHS Board of Trustee meeting to discuss
need for accessible charity care policies and procedures.
Summer 2000:
Community Benefits Taskforce members meet with John Lee, Providence CEO and
Terry Smith, Providence CFO to discuss results of Portland area charity care
research.
September 12, 2000:
Providence hosts meeting between all Portland area hospitals and OHAC to
discuss results of OHAC research and recommendations.
September – December 2000:
Portland area hospitals continue meetings to develop proposal for uniform
financial assistance policies and procedures.
June 2001:
Press conference with OAHHS, Portland hospitals and OHAC to announce uniform
financial assistance policies and procedures.
March 2001 – January 2002:
Periodic meetings between members of the Coalition of Community Health
Clinics and accounts receivable staff of Portland area hospitals to discuss
successes and challenges of single safety net application for hospital
financial assistance.
June 2002:
Meeting scheduled between Portland area Community Benefits Taskforce and
Portland area Hospitals to discuss results of second round of grassroots
research on accessibility of financial assistance policies and procedures.
FINANCIAL ASSISTANCE POLICIES AND
PROCEDURES
BEST PRACTICES AGREEMENT
PORTLAND SERVICE AREA HOSPITALS
November 2000
Income
Guidelines:
·
100% assistance for families at or below 150% FPG.
·
Partial assistance for families between 150-200% of FPG.
·
Case-by-case consideration for assistance for families above 200% FPG.
·
Every step taken to assure a family does not declare bankruptcy from medical
bills.
·
Asset verification may include liquid and non-liquid assets dependent upon
situation.
Cultural
Accessibility:
·
Financial application and materials written at grade school reading level.
·
Materials in four most frequently used languages for demographic area.
·
Other language interpretation available as needed.
·
Published communications such as signs, business cards, in access points of
care, specifically: ED, BO, admitting, urgent care centers.
Public and
Employee Awareness:
·
Hospital staff knows how to refer a person for assistance.
·
Notification of assistance on every bill sent to patients (when technically
possible).
·
Brochure available to public that explains the Financial Assistance process
in user-friendly terminology.
·
Information available during registration process about assistance programs.
User Friendly
Process:
·
Help in completing financial qualification process.
·
Help with completing Oregon Health Plan application process.
·
Coordination with safety net clinics (generic Assistance Applications on
hand the hospitals will accept).
·
Standardize application process in Portland area.
·
Same application process regardless of amount owed.
Collection
Process:
·
No interest or late penalties for families with incomes below 200% FPG.
·
Review any situations where family states medical bills will cause
bankruptcy.
·
Accounts will not be assigned to a collection agency during the Assistance
process.
·
Appeal process that's communicated to all patients who apply for assistance.
·
If a person's situation changes, they can reapply for assistance.
Community Benefits: Need and
Historical Context
Millions of Americans lack
access to health coverage either because their employer does not offer it or
they cannot afford to pay for it. Although Medicaid covers millions of
low-income people, 44 million Americans are not eligible and, therefore,
uninsured. Oregon is no exception. During the 1990s, Oregon's population
grew at a rate twice the national average. As the number of Oregonians
increase, the numbers of residents who are uninsured increase. Despite the
implementation of the state Medicaid program, the Oregon Health Plan, the
uninsured population increased from 340,000 to 420,000 (from 10.6 percent to
11.2 percent of the state's population) between 1997 and 2000.
The majority of people
without health insurance in Oregon work at incomes less than 200% federal
poverty level for employers who do not provide health coverage. They must
choose between putting food on the table, paying for rent, utilities and
childcare, and paying for necessary health care. They are 55% more likely
to postpone care; 4.7 times less likely to obtain prescription drugs; and
four times more likely to use the emergency rooms for non-urgent care needs.
In order to receive
medical services, the uninsured rely on community health clinics, county
health departments, and non-profit hospitals. Access to hospital emergency
rooms is the only access for the uninsured in many parts of the state.
Safety net clinics provide access in the Portland metropolitan area and in
Marion and Polk counties. In addition in the Portland Metro area, the
County Health Department acts as a safety net, providing primary care
services.
Over 85% of acute care
hospitals in Oregon are non-profit or publicly owned, while four are
investor-owned. Non-profit hospitals are owned and operated for the benefit
of local residents under the leadership of a volunteer board of directors.
Non-profit hospitals in the United States have been exempt from taxation
since 1751 when Benjamin Franklin established the Pennsylvania Hospital.
They are exempt from federal and state income taxation as 501(c)(3)
organizations, and from local property taxes under ORS 307.130. In lieu of
taxes, non-profit hospitals provide community benefits: un-reimbursed
health-related services that address a community’s unmet health needs
Charity care is a
critical community benefit provided by hospitals in exchange for their
tax-exempt status. Charity care is free or discounted services provided by a
hospital for people who demonstrate they cannot afford to pay for care.
Hospitals do not expect to receive payment for charity care services.
Despite the critical
role charity care plays, the uninsured are seldom aware of such assistance.
Nationally, medical bills accounted for forty-five percent of personal
bankruptcy filings in 1999. A recent study shows that of the estimated
64,000 uninsured living in Multnomah County (in which Portland resides), 20%
have filed for bankruptcy because of medical bills; 25% are currently paying
off medical bills; and 20% are in collections as a result of medical bill.
Evidently, the uninsured, both nationally and in Portland, are not receiving
adequate information and instructions to access financial assistance for
hospital services. Many who have experienced financial hardship because of
medical bills in Oregon should have qualified for free or reduced-cost care
under existing but unadvertised charity care policies.
Evaluating the availability of charity care
information
To better understand
non-profit hospitals and the vital provision of community benefit - charity
care - Oregon Health Action Campaign’s (OHAC) Community Benefits Task Force
monitored the accessibility of hospital charity care policies in three
communities: Marion and Polk; Portland metropolitan and Lincoln County.
This report highlights the Portland are work.
Methodology
The charity
care-monitoring project conducted by the Oregon Health Action Campaign
(OHAC) was designed to engage community leaders in assessing the ability and
willingness of non-profit hospitals to communicate with uninsured
representatives seeking information about financial assistance. From the
perspective of the community and potential users of financial assistance,
OHAC aimed to explore and document:
·
whether a hospital has a
written formal charity care policy;
·
how easy or difficult is it to
find out about the charity care policy;
·
what steps the hospital takes
to inform people about free or discounted care; and
·
what the process of obtaining
free or discounted care is like.
Data was gathered over
a two-week period in February and March 2000. Phone and site surveys were
conducted with six Portland hospitals -- Providence, Emanuel, Tuality, OHSU,
Portland Adventist, and Good Sam.
Twelve volunteer
community agency representatives, uninsured individuals, and activists
participated in a three-hour training that instructed volunteers on how to
seek and document information about the charity care policies of each
selected hospital. Each volunteer was provided with a written script to
guide him or her through the charity care monitoring process
Uninsured callers
telephoned general hospital numbers and sought information about charity
care policies. Each volunteer phoned a minimum of three different hospitals
at three different times; two times during business hours and one time
during weekend hours. Each of the volunteer callers dialed a hospital’s
general telephone number and asked if charity care is available when
someone’s income is limited. Calls were made by English and Spanish
speakers.
Other volunteer
researchers who represented Portland's uninsured walked-in/rolled-in to
hospital emergency departments as well as reception and intake areas. The
volunteers documented any signs about charity care or payment policies and
sought free care policy information on site in emergency departments.
Finally, staff from
community based organizations sought information on charity care for their
clients and potential clients needing health services by telephoning each
hospital’s financial department. In total, each hospital was contacted 6
times
Summary of Findings
Most hospital
employees, had little or no knowledge of Portland hospitals’ charity care
policies. In all instances, hospital staff stated that “no one will be
turned away due to an inability to pay”. Unfortunately, they rarely knew if
financial assistance existed or how to access such information. Only three
times out of a total of 36 contacts did a volunteer access a financial
assistance application. A charity care policy was obtained only once.
Highlights of the
findings indicate:
·
Community agency
representatives and the uninsured had little access to non-profit hospitals’
charity care policies.
·
Employees knew that their
emergency department does not refuse services regardless of a patient’s
ability to pay. Employees rarely knew, however, about cost or billing
procedures for services received in emergency rooms.
·
Awareness and understanding of
charity care policies varied greatly from employee to employee. Most
hospital employees had little to no knowledge of their employer’s charity
care policies.
·
Charity care was rarely
mentioned unless the caller specifically broached the topic. Even after
directly asking about charity care, most hospital employees were unfamiliar
with the policy.
·
Availability of information on
financial assistance varied greatly among individual employees and depended
on the assertiveness of the volunteer researcher.
·
Several hospitals’ employees
were vaguely aware of a sliding fee scale within their systems.
·
Hospital employees had an
awareness and understanding of the Oregon Health Plan.
·
Oregon Health Plan (OHP)
posters or brochures were often available in emergency departments as well
as reception and intake areas. Information on OHP was available in Spanish
and English only.
·
Monolingual Spanish speaking
persons were unable to access any information (either written or verbal)
pertaining to charity care from any of the approached Portland hospitals.
·
Community based agency staff
were always declined access to the hospitals’ charity care policies.
Community based employees were told by several of the hospitals that they
would send them a copy of the policy and yet copies were never received.
Implications
Community benefits
provided by a non-profit hospital address a community’s unmet health needs
and are developed, prioritized, and implemented in an open community-based
process. According to U.S. history and law, non-profit hospitals are owned
and operated for the benefit of local residents. Charity care is a critical
community benefit provided by hospitals in exchange for their tax-exempt
status.
Charity care is one of
the few sources of affordable care for the uninsured. It is vital for
hospitals to effectively communicate their charity care policies to the
public. When non-profit hospitals fail to adequately inform the uninsured
about their financial assistance opportunities, they prevent access to
health care. This study showed that while each Portland Metropolitan
hospital has free or reduced-care, the policies and procedures of charity
care are inconsistent and frequently unknown by hospital employees.
As a result of this
research and other projects addressing community benefits around the United
States, OHAC’s Portland Community Benefits Task Force developed “Best
Practices of Charity Care.”
Next Steps
§
Portland area hospitals have
collaborated with the Coalition of Community Health Clinics, Tri County
Communities in Charge and OHAC to put together a financial assistance manual
for clinic, county, patient accounts, and outreach workers working to help
people apply for financial assistance and/or the OHP. The book describes
services covered by each hospital under the financial assistance agreement
and who to call with application problems or questions. It includes the
brochures and business cards used by each hospital.
§
A simple, 5th grade
language brochure is being developed for distribution to the public at
large. The brochure starts with the simple question: “Do you need help
paying your hospital bill?”; describes the help that is available and how to
apply.
§
Nurture the community
awareness and relationships necessary to encourage hospitals in additional,
targeted Oregon communities to adopt financial assistance policies and
procedures recommended by OAHHS.
§
Work with all hospitals in
areas that have adopted financial assistance policies and procedures to
coordinate outreach and application assistance for the Oregon Health Plan.
§
Collaborate with all hospitals
in areas that have adopted uniform financial assistance policies and
procedures to develop a process that engages the medically vulnerable or
organizations that represent them in identifying and prioritizing community
benefits responsive to community health need.
§
Evaluation of results of the
implementation of financial assistance policies and procedures, particularly
the safety net/hospital collaboration. Evaluation components to include, at
a minimum: Numbers of referrals for charity care approved/denied; reasons
for denial; Average turn around time for decision; total dollar amount
requested; total dollar amount approved.
APPENDIX 1
Statement of Ellen Pinney, Executive
Director
Oregon Health Action Campaign
06-12-01
Oregon Hospital Financial Assistance
Guidelines;
A Well-Considered Response to Community Health Need
Uniform hospital
financial assistance policies and procedures were not developed or put in
place over the course days, weeks or even months. They were developed in
response to real and researched community need. They were developed thanks
to the leadership, foresight, creativity and dedication of some brave and
innovative hospital administrators and community members. The collaboration
that forged these guidelines was not always easy or smooth for everyone
involved. But all of us chose to put our differences to the side and focus
on the result. I believe I speak for everyone here when I say that we have
a product we can be proud of.
In the Portland
metropolitan, Marion-Polk and Lincoln County areas, we stand at the
beginning of a new day for people whose outstanding medical bills and fear
of incurring additional debt keep them out of the health system or force
them into collections or bankruptcy.
My job is to provide
background and context.
The Oregon Health
Action Campaign (OHAC) is a coalition of individuals and organizations
committed to empowering the consumer voice in the development of health
systems that give all people access to the care they need, when they need it
from providers of their choice at an affordable cost.
Over the years, OHAC
has received an increasing number of calls from people who are unable to pay
medical bills and feel threatened by potential or actual collection action.
The stories some of them are willing to share reveal that when people are
struggling to pay medical bills or are forced into collections or bankruptcy
because of unpaid medical bills, they are reluctant to return to the health
system in any way. They do not enroll in the Oregon Health Plan. they
delay treatment for health conditions that can worsen and will cost much
more to treat if and when an emergency room visit becomes essential.
The stories OHAC has
heard are substantiated by facts:
1. Research in the Portland area
revealed that 20% of the uninsured were paying off hospital bills; 25% were
in collections because of medical bills; and 20% had filed bankruptcy
because of medical bills (June 28th, Communities in Charge
Forum, Multnomah County Health Department).
2. 45% of all non-business
bankruptcies filed in the United States were precipitated at least in part
by the financial consequences of medical problems. (Norton's Bankruptcy
Advisor, May 2000).
3. The more formal research OHAC did
in the Portland and Salem areas showed that while all hospitals and all
staff in the hospitals we surveyed consistently and clearly stated to all
who asked that no one would be turned away because of inability to pay,
information about the availability of charity care or financial assistance
policies was close to impossible to get. In all but four or five instances
(out of more than 100) were any of our researchers given either policies,
applications or information about the availability of charity care or
financial assistance policies.
When OHAC presented
its findings to Dennis Noonan, Salem Hospital CEO, in the latter part of
1999, he wasted no time in convening all four hospitals in the Marion/Polk
County area to discuss how best to respond. Their proposal and subsequent
agreement, announced in March of 2000, was bold and unprecedented. It
reflected collaboration across unaffiliated hospital systems and informed
responsiveness to community need. It established the standard for future
discussions.
Similar community-run
research in the Portland area provided the impetus for the Portland area
hospitals to come together. The thoughtful and deliberate process chaired
by Terry Smith, Providence CFO, resulted in the recommendations you have
before you today. These recommendations have been accepted and are being
implemented by all Portland area hospitals and by two hospitals in Lincoln
County. The work, done in the private sector and out of the heat of
legislative wrangling, proves again that Oregon is a national leader in
innovative and collaborative approaches to addressing the needs of those
currently underserved by our health system. We believe this voluntary
agreement sets a national precedent.
As is too well known,
agreement on policy is just the first part of the effort. The hard work is
yet to come: implementation, evaluation, fine-tuning, and public outreach.
Most significantly, OHAC views charity care / financial assistance as only
one vital and substantive component of a much larger obligation that all
non-profits have to fulfill a charitable mission. We look forward to our
continuing work with Oregon hospitals to engage community members in the
process of prioritizing, recommending and evaluating community benefits
provided in response to unmet health need.
The work the Oregon
Health Action Campaign has done over the years to research and develop
community benefits organizing models in Marion/Polk, Lincoln and the
Portland Metropolitan areas could not have happened without the support and
dedication of many organizations and individuals. I want to pay special
tribute to Community Catalyst, The Access Project, Multnomah County's
Communities in Charge, Surdna and the Northwest Health Foundation. This
document is a testament to the process employed in the Portland Area.
APPENDIX 2
Portland Service Area
Hospital Financial
Assistance
Best Practices
December 2000
Co-Sponsors:
Oregon Association of
Hospitals and Health Systems
Oregon Health Action
Campaign
Purpose Statement
Portland Service Area
Hospitals
Financial Assistance / Charity Task Force
December 2000
|
Agree to a common process that ensures Portland Area Hospitals meet
their community obligations to provide financial assistance in a
fair, consistent, and objective manner.
|
Participating Groups:
Adventist Health NW
Network
Coalition of Community
Health Clinics
Kaiser Permanente
Legacy Health System
Multnomah County
Native American
Rehabilitation Association
Neighborhood Health
Clinics
North Portland Nurse
Practitioner Clinic
Oregon Association of
Hospitals and Health Systems
Oregon Health Action
Campaign
Oregon Health Science
University
Outside In
Providence Health System
Tuality Healthcare
Wallace Medical Concern
Willamette Falls
Hospital
Oregon Association
of Hospitals and Health Systems Participants:
·
Kaiser Permanente Andee Petersen
·
Legacy Health System Pamela Vukovich
·
Portland Adventist Mark Perry
·
Providence Health System Terry Smith
·
Tuality Healthcare Tim Fleischmann
·
University Hospital Aaron Crane
·
Willamette Falls Hospital Tim Blanchard
·
OAHHS Ken Rutledge
OAHHS Business
Services Committee Participants:
·
Kaiser Permanente Dan Remington
·
Legacy Health System Kathie Dias, Earlene Phillips
·
Portland Adventist Kenneth Mitchell, Donna
Krenzler
·
Providence Health System Teresa Spalding
·
Tuality Healthcare Jean Smith, Jackie Nutt
·
University Hospital Debra Tomsen
·
Willamette Falls Hospital Dawn Burns, Carol Duncan
·
OAHHS Kent Ballentyne
TABLE OF CONTENTS
BEST PRACTICES
1-9
Foundation of
the Best Practices Agreement 1-2
Comments by OHAC
on Committees Best Practice Recommendations 3-5
Best Practice
Recommendations Offered by OHAC 6-7
Best Practice
Agreement 8-9
COMMON
PRACTICES
10-11
Financial
Assistance Screening 10
Safety Net
Assistance Application
Sample Hospital
Statement
Account
Follow-up and Collection Practice 11
LEGAL PRACTICES
12
Hospital Lien
Clarification 12
Portland Service
Area Bankruptcy Review 12
COMMUNICATION
13-15
Sample Brochure
#1 13
Sample Brochure
#2 14
Sample Business
Cards 15
Sample Wall
Sign 15
NEXT STEPS
16-19
Financial
Assistance Policy 16
Employee
Education Program 16
Ongoing
Monitoring 16
Annual Follow-up
Meeting 16
Sample Financial
Assistance Policy 17-19
MISCELLANEOUS
20-26
Minutes from
OAHHS and OHAC Board Meeting 20-21
Minutes from
OAHHS and
OHAC Update on Committee 22-23
Meeting
Schedule and Plans 24-26
BEST PRACTICES
FOUNDATION OF THE
BEST PRACTICES AGREEMENT
On September 12,
2000, Portland area members of the Oregon Association of Hospitals and
Health Systems (OAHHS) met with representatives of the Oregon Health Action
Campaign (OHAC) to discuss "best practices" in financial assistance. It was
agreed that hospitals would convene a local task force with a goal of
establishing a consistent and standardized approach to financial
assistance/charity. As a beginning, OHAC outlined "best practices" in the
areas of income guidelines, cultural accessibility, public and employee
awareness, user friendly standardized application, and collection and lien
practices (pg. 7-8). Existing practices of Portland area hospitals will be
evaluated to determine "best practices."
For the past few
months, representatives of Portland OAHHS member hospitals participated in
the assigned task force reviewing and seeking to implement the best
practices from OHAC and existing financial assistance programs available
within the community.
Consensus was reached
on a core level of financial assistance best practices including:
CORE LEVEL
AGREEMENTS AMONG GREATER PORTLAND AREA HOSPITALS:
ü
Hospital policies will reflect the core level agreements.
ü
Minimum assistance levels are tied to Federal Poverty Guidelines (FPG).
ü
Sliding fee scales allowing for situational exceptions for families above
150% of FPG.
ü
Common application processes for all services and locations will be made
available.
ü
Written materials explaining assistance programs readily available at major
registration sites in appropriate languages.
ü
Continuing education and communication of assistance programs to employees
will be implemented and monitored.
ü
Final determination and qualification for financial assistance may vary from
hospital to hospital based on each hospital's screening process.
COMMITTEE
OUTCOMES
1. Financial assistance hospital
policies will be updated to reflect the agreed upon core agreements.
2. Financial assistance will be 100%
for families 150% below FPG. A sliding fee scale, plus situational
consideration will be available when family income is above 150% FPG.
3. Sliding fee scales will be
updated annually in conjunction with the FPG updates.
4. A hospital's financial assistance
application and approval process will be the same regardless of service
provided or amount of the bill.
5. Prior to any collection agency
assignment, a patient's previous history will be reviewed to confirm if a
financial assistance determination was previously made.
6. Patients can reapply for
financial assistance, before, during or after care or after collection
agency assignment if their situations change.
7. A standard Safety Net Clinic
Assistance Application was developed (pg. 11). Hospitals will make
financial assistance determinations from the Safety Net Clinic Assistance
Application form when presented and complete.
Hospitals may have their own
assistance application form; however, the Safety Net Clinic Application will
be honored, as well as other hospital's application form, provided all
needed information is present.
8. Business cards notifying people
of financial assistance programs and where to telephone for assistance will
be located throughout the hospital. The Cards will be printed in up to four
languages sensitive to that service area (pg. 18).
9. Interpreter services will be
available for individuals to assist in completing the financial assistance
application process.
10. Signage notifying people of
financial assistance programs will be available along with telephone numbers
on where to call in most major registration sites of hospitals (pg. 19).
11. Brochures written in "user
friendly" language that outlines the assistance application process that may
be available at registration sites (pg. 16 and 17). Brochures may be
available in multiple languages.
12. Financial assistance programs will
be communicated annually to employees. The goal is for employees to know
how and where to refer a person with a financial hardship (pg. 20).
13. Hospitals will develop processes
to self-monitor the success of their communications and ease for patients to
access assistance programs (pg. 20).
14. In December 2001, the Portland
area hospitals will meet to review and update financial assistance "best
practices." Providence Health System will coordinate and host the meeting.
15. The OHAC Best Practices that could
not be implemented are detailed in pages 4-6 and pages 13-14.
COMMENTS BY
OHAC ON COMMITTEES BEST PRACTICES RECOMMENDATIONS
November 2000
Representatives from
OAHHS and OHAC met to review progress and outcomes of the task force.
OHAC’s Taskforce provided feedback based on experience with the targeted
population and easy of processing applications. OAHHS representatives
detailed comments listed.
Scale:
·
Task force comments/agreement to OHAC recommend Best Practices.
Þ
Comments noted by OAHHS representative from meeting with OHAC.
Income Guidelines:
·
100% assistance for families at or below 150% FPG. Partial assistance for
families between 150-200% of FPG.
Þ
This is OK but could we also discount the amount of the patient's bill
that is being prorated? OHAC would like to think that a partial payment
could be made on a partial bill, not the full-billed charges.
·
Case-by-case consideration for assistance for families above 200% FPG.
·
Every step taken to assure a family does not declare bankruptcy from medical
bills.
Þ
OK.
·
Asset verification include only liquid assets.
Þ
Oregon Health Plan does not go beyond liquid assets. The fact that a
person has other debt besides the hospital should be considered. That would
include credit cards, etc.
Cultural
Accessibility:
·
Financial application and materials written at 5th grade reading
level.
Þ
5th or 8th grade level, it doesn't make a big
difference.
·
Materials in four most frequently used languages for demographic area.
·
Other language interpretation available as needed.
Þ
No big deal. We spoke about the various areas and the different
languages that might be needed. OHAC's concern is the same as the Civil
Rights rules as far as access to languages. We should be fine.
Public and
Employee Awareness:
·
All hospital staff knows how to refer a person for assistance.
Þ
The education programs will be sufficient if staff can direct an inquiry
to financial assistance.
·
Notification of assistance on every bill sent to patients.
Þ
I explained that this may not appear on all statements as some are
produced centrally for some systems and do not apply to a specific
hospital. That seemed OK.
·
Brochure available to anyone who asks (policies or principals).
Þ
This is a good idea.
·
In registration process, check the box if person wants information on
assistance programs.
Þ
I explained that this would not be done. I explained that the hospital
would make all the resources available but that the incentive is the
patient's responsibility and not the hospital's.
User Friendly
Process:
·
Help in completing financial qualification process.
Þ
Good. All they are looking for is assistance for people that don't
understand how to make and follow-up on the application. A business office
contact would make that happen.
·
Help with completing Oregon Health Plan application process.
Þ
They would like the same services as above for the OHP.
·
Coordination with safety net clinics (clinics having financial
qualifications on hand).
Þ
The clinics have people on hand to assist with the OHP. Is it possible
to have copies of the financial assistance forms also? This anticipates a
single form for application not for determination. The safety net clinics
do not make decisions on granting assistance merely help potential
assistance recipients fill out the form to apply.
·
Standardize application process in Portland area.
Þ
OHAC would like to see one form all around the area.
·
Same application process regardless of amount owed.
Þ
OK.
·
Supportive, scripted dialogue on how to present option of assistance.
Þ
This would be helpful if it could be worked out.
Collection and
Lien Process:
·
No interest, late penalties for families with incomes below 200% FPG.
·
Review any situations where family states medical bills are going to cause
bankruptcy.
Þ
Good.
·
Hold accounts six months before any collection agency assignment.
Þ
No. Too many variables that need to be considered. I did say that as
long as a person is working with the hospital in an effort to resolve
eligibility they would not be turned to collection.
·
If payment plan broken, contact to family to re-screen for assistance.
Þ
The initiative is the patient's, not the hospital's. The hospital will
have to pursue the account until the patient comes forward with new
eligibility.
·
Send collection agency assignment notices certified mail.
Þ
I explained that this was too expensive. Ellen told me that many people
are too overwhelmed to read all the bills that they get and won't realize
that they are being turned until it is too late. I told her that it was the
patient's responsibility to contact the hospital. This may be a point of
future discussion. OHAC seems to think that certified mail is important.
·
Review all accounts at collection agencies to determine if they qualify for
assistance.
Þ
Once again, I explained that each patient must contact the hospital for
assistance.
·
Way for person to clear credit history on previous bad debt accounts.
Þ
Not legal. Out of the hospital's hands once it has been turned.
·
Not send to collection agency until after determination made.
·
Appeal process in place, communicated to all patients who apply for
assistance.
·
When person's situation changes, let them reapply for assistance.
Þ
OK.
·
Don't file liens against people's assets or property/needs clarification.
The groups spent several hours talking about
the issue of liens and how they were used by hospitals. OHAC indicated that
their research implicated some hospitals for filing up to 40 liens per day
while others filed hardly any. The OHAC assumption is that some hospitals
are more aggressive than others in pursuing payments. It is not clear from
any work group whether this has been clarified. A plan is in process to
monitor and assess lien practices and bankruptcy data as reported in
Bankruptcy Court and gathered by OHAC members.
After
reviewing the work that the Hospital Systems completed OHAC offered this
additional information.
BEST PRACTICES
RECOMMENDATIONS OFFERED BY OHAC
Income Guidelines:
·
100% assistance for families at or below 150% FPG.
·
Partial assistance for families between 150-200% of FPG.
·
Case-by-case consideration for assistance for families above 200% FPG.
·
Every step taken to assure a family does not declare bankruptcy from medical
bills.
·
Asset verification include only liquid assets.
Cultural
Accessibility:
·
Financial application and materials written at 5th grade reading
level.
·
Materials in four most frequently used languages for demographic area.
·
Other language interpretation available as needed.
·
Published communications such as signs, business cards, in access points of
care, specifically: ED, BO, admitting, urgent care centers.
Public and
Employee Awareness:
·
All hospital staff knows how to refer a person for assistance.
·
Notification of assistance on every bill sent to patients (when possible).
·
Brochure available to anyone who asks that is user friendly and explains the
Financial Assistance process.
·
In registration process, check the box if person wants information on
assistance programs.
User Friendly
Process:
·
Help in completing financial qualification process.
·
Help with completing Oregon Health Plan application process.
·
Coordination with safety net clinics (clinics having financial
qualifications on hand).
·
Standardize application process in Portland area.
·
Same application process regardless of amount owed.
·
Supportive, scripted dialogue on how to present option of assistance.
Collection and
Lien Process:
·
No interest, late penalties for families with incomes below 200% FPG.
·
Review any situations where family states medical bills are going to cause
bankruptcy.
·
Hold accounts six months before any collection agency assignment.
·
If payment plan broken, contact to family to re-screen for assistance.
·
Send collection agency assignment notices certified mail.
·
Review all accounts at collection agencies to determine if they qualify for
assistance.
·
Way for person to clear credit history on previous bad debt accounts.
·
Not send to collection agency until after determination made.
·
Appeal process in place, communicated to all patients who apply for
assistance.
·
When person's situation changes, let them reapply for assistance.
·
Don't file liens against people's assets or property/needs clarification.
Oregon Health
Action Campaign PREFERRED FOLLOW-UP GOALS:
1. Work groups established to
address the implementation process, i.e. train gin, problem solving and the
like
2. Communicate our goals to them.
3. Communicate how health systems
will evaluate our own activities in future for financial assistance.
4. Oregon Health Action Campaign
would like to participate in the implementation process for all Portland
area hospitals financial assistance policies implementation.
5. Would like overview of how all
Portland area hospitals handle collections and follow-up. Example: if use
collection agencies, statements, action steps, and communications to
patients.
After
reviewing OHAC’s comments and further suggestions, the OAHHS lead work group
developed the following:
BEST PRACTICES
AGREEMENT – PORTLAND SERVICE AREA
November 2000
Income
Guidelines:
·
100% assistance for families at or below 150% FPG.
·
Partial assistance for families between 150-200% of FPG.
·
Case-by-case consideration for assistance for families above 200% FPG.
·
Every step taken to assure a family does not declare bankruptcy from medical
bills.
·
Asset verification may include liquid and non-liquid assets dependent upon
situation.
Cultural
Accessibility:
·
Financial application and materials written at grade school reading level.
·
Materials in four most frequently used languages for demographic area.
·
Other language interpretation available as needed.
·
Published communications such as signs, business cards, in access points of
care, specifically: ED, BO, admitting, urgent care centers.
Public and
Employee Awareness:
·
Hospital staff knows how to refer a person for assistance.
·
Notification of assistance on every bill sent to patients (when technically
possible).
·
Brochure available to public that explains the Financial Assistance process
in user-friendly terminology.
·
Information available during registration process about assistance programs.
User Friendly
Process:
·
Help in completing financial qualification process.
·
Help with completing Oregon Health Plan application process.
·
Coordination with safety net clinics (generic Assistance Applications on
hand the hospitals will accept).
·
Standardize application process in Portland area.
·
Same application process regardless of amount owed.
Collection
Process:
·
No interest or late penalties for families with incomes below 200% FPG.
·
Review any situations where family states medical bills will cause
bankruptcy.
·
Accounts will not be assigned to a collection agency during the Assistance
process.
·
Appeal process that's communicated to all patients who apply for assistance.
·
If a person's situation changes, they can reapply for assistance.
COMMON PRACTICES FOR FINANCIAL ASSISTANCE
SCREENING
(Hospital mission statement goes here)
Request for financial
assistance may be made at any point before, during, or after the provision
of care. The hospital will use an application process for determining
initial interest in and qualification for financial assistance.
A responsible party
not choosing to apply for financial assistance will not be considered for
assistance unless sufficient information is available to make a final
determination without an application.
The hospital's
decision to provide financial assistance in no way affects the responsible
party's financial obligations to their physician or other healthcare
providers. Requests for financial consideration may be proposed by sources
such as physicians, community or religious groups, social services, hospital
personnel, the patient, responsible party, or family member.
Financial assistance
is specific to each admission of the patient. New or readmission will be
screened for changes in eligibility for financial assistance.
Financial assistance
is granted for medically necessary procedures only. A Business Office
representative should be consulted in special situations.
Financial assistance
is secondary to all other financial resources available to the patient,
including insurance, government programs, third party liability, and
assets. (Hospital) assists persons with financial need by waiving all or
part of the charges for services provided by (hospital).
These are generally
accepted guidelines; however, each individual situation will be reviewed
independently. Allowances may be made for extenuating circumstances.
COMMON ACCOUNT FOLLOW-UP AND COLLECTION
PRACTICE
OHAC requested
hospitals submit information on how their account and collection process
occurs. After significant discussion and review, it was determined one
common theme is used in all sites. the following outlines the most typical
account follow-up process.
1. Service is provided.
2. 5-30 days later statement to
patient showing services provided and amount owed.
3. 30 days later request for payment
mailed.
4. 30 days later, Past Due Notice
mailed.
5. 30-45 days later notice stating
account may be assigned to collection agency if no contact from patient.
6. Most hospitals attempt at least
one telephone contact during the process. The number of telephone contacts
is dependent upon the amount owed, or identified extenuating circumstances
with the patient.
7. All participants agreed if
responsible party contacts hospital at any point in the process,
intervention would occur that changes the timing cycle to allow time to
resolve account. Outcomes may include, but are not limited to establishing
a payment plan, providing a financial assistance application, billing
insurance, if information provided.
8. Participants agreed once an
account goes to a collection agency, the expectation is the collection
agency makes every attempt to collect the debt. If the collection agency
identifies a financial hardship with a debtor, they may educate the debtor
how to apply for financial assistance with the hospital.
LEGAL
PRACTICES
HOSPITAL LIEN
CLARIFICATION
OHAC questioned why
some hospitals file what appeared to be a significant volume of liens
against patients. After review, committee members believed there was a
misunderstanding as to the type and reason the liens are filed. OAHHS Legal
Council in conjunction with the committee provided this clarification.
Hospitals are
typically involved in two types of liens:
Liens pursuant
to ORS 87.555
These liens result from medical care
provided as a direct result of accident or injury that may result in sums or
proceed settlements. These liens are not against a person's
personal property or assets, and involve no Court action.
The lien under ORS 87.555 establishes a
hospital or physician lien that attaches to any sum awarded as damages, in
the form of judgment, settlement or compromise, to an injured person or to
his or her personal representative. That statute also allows a hospital to
have a lien against amounts payable to an injured person under an insurance
policy providing personal injury protection (not a health insurance policy).
The amount of the lien is limited to the
amounts due the hospital for the reasonable value of the hospitalization or
treatment in the hospital. There is no provision for a lien in favor of a
hospital providing care to a person for reasons other than injury.
Liens pursuant
to Court Judgment
Typically, these liens result from legal
action from a collection agency in pursuit of debt repayment. These liens
may be against person's assets.
By statute, a
hospital may not file a lien against a patient who comes under the Workers'
Compensation Act.
It is often assumed
that a lien filed under the statute is a lien against personal assets. It
is not. This occurs because most people are unaware of ORS 87.555.
PORTLAND SERVICE
AREA BANKRUPTCY REVIEW
A review of the
Portland Area Hospital lien process will further inform bankruptcy claims.
National data indicates over 40% of all bankruptcies are due in part to
medical bills. Research in Portland indicated that many noted bankruptcy
filings included some medical and dental bills. However, the initial study
should be expanded to provide a large enough sample to make some informed
determinations of the low-income clients experience herein.
Conclusion
The number of uninsured continues to grow despite the
implementation of the Oregon Health Plan in 1993. Welfare reform has meant
more people leaving the welfare system for jobs that pay too much to qualify
workers for government health coverage but that offer no affordable health
insurance of their own. Fewer employment opportunities including
employer-sponsored health insurance and the increase in the State's minimum
wage forces many families just above the poverty level and therefore
ineligible for Medicaid. Many uninsured address more immediate demands in
their lives and incur exorbitant medical bills due to sudden illnesses,
accidents, death of family members, and major illnesses.
Ten percent of those living in the Portland
Metropolitan area have no health insurance. Too often, their health is
dictated by the cost of health care. Ironically and tragically, the
uninsured address more immediate demands in their lives and incur exorbitant
medical bills due to sudden illnesses, accidents, death of family members,
and major illnesses. Nearly all Portland area hospitals are non-profit and,
therefore, have a legal obligation to benefit the community, the uninsured
are frequently unable to access financial assistance. Too often, the
uninsured are not clearly informed of a hospital’s assistance program.
Furthermore, most hospital employees have little awareness of their
employer’s charity care program. Catastrophically, even when a patient knows
exactly what to ask for, charity care policies and procedures are nearly
impossible to obtain.
Much of the information gained by the charity care
monitoring process is deeply disturbing. These findings, however, were
presented to local hospital administrators in September, 2000. Several OHAC
representatives began an inclusive dialogue with hospital administrators.
This is a significant step toward Portland Community Benefits Task Force’s
goal of creating a collaborative, on-going process of identifying,
discussing, prioritizing and evaluating unmet community needs and the
success of health-related services designed to address those unmet needs.
Both local non-profit hospitals and the Oregon Association of Hospitals and
Health Systems agreed to work with Oregon Health Action Campaign to improve
and standardize charity care policies and procedures for the uninsured of
Oregon. Presently, Chief Financial Officers and Business Managers of each of
the Portland non-profit hospitals are deliberating over charity care best
practices. They will report their findings to OHAC who will continue to
empower the consumer voice in the development of quality, responsive health
systems that allow all people to access the health care they need, when they
need it from the providers of their choice at an affordable cost.
NEXT STEPS
Financial
Assistance Policy
Each hospital is
proceeding with the steps necessary to update, gain approval and implement a
Financial Assistance Policy that incorporates the core agreements.
Employee Education
Program
Each hospital will
identify the most effective method to provide annual financial assistance
education to all employees.
Examples of where
education can be provided:
·
New Employee Orientation
·
Employee Health and Safety Fairs
·
Management Forums
·
System Newsletters
·
Inserts in paychecks
·
Part of Business Office annual employee reviews
On-Going
Monitoring
Participants
supported self-monitoring of the effectiveness of education and
communications.
Examples of how
sites may self-monitor:
·
Send "test patients" through the care process, similar to OHAC process
·
Visit care department unit meetings and ask how to access assistance
·
Make "blind" calls to different departments asking for assistance
·
Monitor volumes of assistance, and numbers of applicants
·
Monitor volumes of assistance AFTER collection agency assignment
·
Solicit patient feedback on the easy of finding out about, and applying for
assistance
Additionally, OHAC has made itself available
for assistance in the monitoring process as OHAC will be following up
separately with the agreed upon process.
Annual Follow-up
Meeting
In December 2001, a
follow-up meeting will be held for OAHHS members to review the impact of
these changes along with any new "best practices."
Appendix 3
PORTLAND AREA
FINANCIAL ASSISTANCE APPLICATION / SAFETY NET CLINIC
|
To apply for
Financial Assistance at a Portland Area Hospital: |
|
1.
Complete this application. |
|
2.
Attached copies of: Previous year's tax returns AND verification
showing year to date income or last 3 months pay stubs. |
|
3.
Submit to Business Office at hospital where care was provided. |
|
GENERAL
INFORMATION |
|
|
|
|
|
Patient's
name Last First
M.I. Social Security
Number Date of birth |
|
ð
Yes ð
No
|
|
U.S.
Citizen Marital status Spouse's
name Last First M.I.
Telephone No. Home / Work |
|
|
|
Person
responsible for paying the bill
Relationship to patient
Telephone No. Home / Work |
|
|
|
Number of people
in household Ages of people in household |
|
|
|
Health insurance
coverage (company name, ID#) |
|
|
|
HOUSEHOLD INCOME |
|
|
|
|
PERSON 1 |
PERSON 2 |
PERSON 3 |
|
NAME: |
|
|
|
|
RELATIONSHIP TO
PATIENT: |
|
|
|
|
Monthly gross
income (attach verification) |
$
|
$
|
$
|
|
Unemployment, if
so, how long |
$
|
$
|
$
|
|
Social Security,
pensions |
$
|
$
|
$
|
|
Alimony/child
support |
$
|
$
|
$
|
|
Government
assistance, food stamps |
$
|
$
|
$
|
|
Other sources of
income |
$
|
$
|
$
|
|
Checking account
balances |
$
|
$
|
$
|
|
Savings account
balances |
$
|
$
|
$
|
|
Stocks, bonds,
IRA's, investments |
$
|
$
|
$
|
|
Other assets |
$
|
$
|
$
|
|
|
|
AUTOMOBILE /
VEHICLE |
|
|
|
|
VEHICLE 1 |
VEHICLE 2 |
VEHICLE 3 |
VEHICLE 4 |
|
Make / Year |
|
|
|
|
|
Monthly payment |
|
|
|
|
|
Value |
|
|
|
|
|
|
|
MONTHLY EXPENSES
/ BILLS |
|
|
|
ð
Rent $
ð
Monthly Mortgage $
Mortgage Balance $ Equity
$ |
|
Utilities |
$
|
Alimony/Child
support |
$
|
|
Credit cards
(total) |
$
|
Health insurance |
$
|
|
Insurance
(vehicle/life/property) |
$
|
Healthcare bills |
$
|
|
Child care |
$
|
Medications |
$
|
|
Living, i.e. gas,
food, clothes |
$
|
Entertainment |
$
|
|
Other |
$
|
Other |
$
|
|
|
|
COMMENTS OF
EXTENUATING SITUATION (attach another page if needed) |
|
|
|
|
|
|
|
x
|
|
Responsible
Person's
Signature
Date |
|
I certify the
information contained above is correct and complete to the best of
my knowledge, and may be verified by hospital. |
| |
|
|
|
|
|
|
Referring Safety Net
Clinic:
Safety Net Clinic
Contact Name:
Oregon Health Plan (OHP)
Patient pre-screened for
OHP: ð
Yes ð
No
OHP screener name &
phone number:
OHP application
submitted:
ð
Yes ð
No
Status:
Actions
needed:
Comments:
Please staple a copy
of OHP application and/or other information relevant
to financial
assistance to this form
[HOSPITAL]
GENERAL OPERATING POLICY
SUBJECT: FINANCIAL
ASSISTANCE/SERVICES
I. OBJECTIVES
To ensure that
[Hospital] meets its community obligations to provide financial assistance
in a fair, consistent and objective manner.
II. POLICY STATEMENT
A. It is both the
philosophy and practice of [Hospital] that medically necessary health care
services should be available to all individuals, regardless of their ability
to pay.
B. [Hospital]
assists persons with financial need by waiving all or part of the charges
for services provided by [Hospital].
III. PROCEDURE
A. Eligibility
Criteria
1. Financial
counselors and Business Office personnel are available to help patients
identify financial options or assistance programs.
2. Financial
assistance is generally secondary to all other financial resources available
to the patient, including insurance, government programs, third-party
liability and assets.
3. Full
financial assistance usually will be provided to a responsible party with
gross family income at or below 150% of Federal Poverty Guidelines (FPG).
4. A sliding-fee
scale will be used to determine financial assistance discounts when gross
family income is above 150% of FPG.
5. Notification
of financial assistance determinations will be mailed to the responsible
party. Reasonable payment arrangements consistent with the responsible
party's ability to pay will be extended for amounts owed.
B. Eligibility
Determinations
1. The provision
of health care should never be delayed pending an assistance determination.
2. Requests for
financial assistance may be made at any point before, during or after the
provision of care.
3. Financial
assistance requests may be proposed by sources other than the patient, such
as the patient's physician, family members, community or religious groups,
social services, or hospital personnel.
4. Anyone
wishing to make application for financial assistance with [Hospital] will be
given a Financial Assistance Application, which includes instructions on how
to apply.
5. Consideration
for financial assistance will occur once the applicant supplies a completed
Financial Assistance Application with supporting documents to the [Hospital]
Business Office.
6. [Hospital]
will make every attempt to make assistance determinations within 20 days of
receiving a completed Financial Assistance Application.
7. Consideration
for assistance includes a review of the responsible party's annual household
income, number of people in the home, assets, credit history, existing debt
and other indicators of the party's ability to pay. These are merely
guidelines; each individual situation should be reviewed independently.
Allowances may be made for extenuating circumstances.
8. Acceptable
verification of income includes the following: the most current 90 days'
worth of payroll stubs; a copy of the most current year's IRS tax return;
verification of Social Security or unemployment benefits. In the absence of
income, a letter of support from individuals providing for the patient's
basic living needs will be accepted.
9. [Hospital]
will keep all applications and supporting documentation confidential.
[Hospital] may, at its own expense, request a credit report to further
verify the information on the application. Incomplete applications may be
denied and returned with a statement of what information is needed and how
to reapply.
10. Financial
assistance may be denied if application is not completed and returned to
[Hospital] within 20 days of receipt by the responsible party.
11. Financial
assistance will not be considered without a completed Financial Assistance
Application unless sufficient like information can be obtained that allows
for a final determination without an application. In extenuating
circumstances, where it can support a financial hardship exists; [Hospital]
may offer financial assistance at its own determination.
12. Financial
assistance is not granted for some procedures, such as elective cosmetic
surgery or some special situations, such as that of an individual who is
eligible for insurance but has refused to apply. A Business Office
financial counselor should be consulted in these special situations.
C. Appeals
Responsible parties may
appeal a financial assistance determination by providing additional
information, such as income verification or an explanation of extenuating
circumstances, to the Business Office director within 30 days of receiving
notification. The Business Office director will review all appeals. The
responsible party will be notified of the appeals outcome. Collection
follow-up on accounts will be pended during the appeal process.
APPROVED BY:
Chief Executive Officer
Date
MISCELLANEOUS
MINUTES FROM OAHHS AND
OHAC BOARD MEETING
The meeting was called to order by OAHHS chair, Jim Lussier. Mr. Lussier
asked Ken Rutledge to introduce the guest speaker. Mr. Rutledge introduced
Ellen Pinney who is the executive director for Oregon Health Action
Campaign, a healthcare consumer group with a particular focus on the health
needs of low income Oregonians.
The general theme of Ms. Pinney's presentation was on healthcare access for
the under-insured and uninsured who have no or limited ability to pay. The
specific points she made included the following:
·
Hospitals, are a large part of Oregon's safety net, the final line of
defense for people without health insurance needing care and for people with
insurance who are not able to get the care they need through their
insurance.
·
The safety net population includes people below 200% of the federal poverty
level, and is disproportionately represented among the uninsured and
under-insured in the state. [200% of poverty is an after tax income =
$1104/mo for a single person. Such a person on average has monthly expenses
equal to $1336, not including healthcare costs]. This is based on a very
rough market base.
·
Hospitals advise patients that no one is turned away, but after leaving the
hospital, those without the ability to pay typically receive bills from the
hospital and all providers they have seen. Over 50% of one million
bankruptcies filed in the country had significant medical bills attached.
·
Focus group shows 20% of uninsured had back medical bills, 25% had medical
bills in collections and 20% had filed bankruptcy related to medical bills =
65% with some duplication.
·
Many not told about availability of financial assistance. Staff researched
Metropolitan Portland and surrounding counties. They called in person and
by phone asking for financial assistance policies and procedures. Of nine
calls or visits to each hospital, in only two cases was staff able to get
financial assistance policies and procedures.
·
Research also done on liens, which are public information. They found there
was no uniform method of filing liens among hospitals. Some hospitals file
as many as 30-40 liens per day and some as few as one lien per day.
Patient's don't know these liens are being filed [seems to be related to
care insurance] and in some cases the insurance carrier also receives a lien
file. Response by one board member was that it's because if a patient is
paid directly by the insurer, it needs to go to the provider. Also, the
lien is made in case there is a lapse in insurance payment whereby the
patient may not even be covered by insurance.
·
Four hospitals [Salem, Santiam, Silverton and Valley] voluntarily agreed to
work together to come up with a uniform financial assistance policy and
application form; to make notices about availability in Spanish and English;
to make signs; hand out cards with telephone numbers; to train all front
line staff.
·
OHAC would like to see, in each community, a more concerted effort by
hospitals to engage the community [uninsured and under-insured] in
discussions about community benefits the hospital is providing.
·
Encourages OAHHS to work with all hospitals in state to come up with
standardized financial assistance policies and procedures that would be
uniform and to make them available in languages at the level of those
needing access [8th grade level] and to make those policies
available to organizations who help people get the healthcare they need.
It's more than reporting, it's engaging a community and listening,
responding and developing a community benefit to provide on front end, then
making sure those benefits address unmet community health needs.
Post presentation discussion included the following items:
·
Jim Lussier asked for matrix/chart referenced in report [marketplace
basket]. Ms. Pinney agreed to label the chart as a very rough,
unprofessional draft, which would pull together information from a lot of
different places.
·
How do hospitals become proactive without actually advertising free care or
financial assistance? Consider stamping invoices "Financial Assistance is
Available to Those Who Qualify. If interested, Call This Number."
·
Problem often occurs outside of hospital provided care [radiologist,
anesthesiologists, etc.]. One hospital signed contracts with physicians to
provide a level of financial assistance under defined types of criteria to
make that link. McMinnville Hospital model allows safety net clinicians to
refer people to their hospital and would accept the same payment plan that
safety net had identified for that patient.
·
Many hospitals cannot contract agreement on these conditions with
physicians. This is a complex problem.
·
Many patients will not respond or follow-through by filling out forms or
providing documentation and many misrepresent their situation on their
forms.
·
Ms. Pinney advised they are developing a list of suggested policies and
procedures around financial assistance to address coordination of care with
other safety net providers in the community. Ms. Pinney will share the list
once it's finalized.
·
Discussion included consideration of a Task Force to pursue solutions
regarding uniform and standardized practices.
MINUTES FROM OAHHS
AND OHAC UPDATE ON COMMITTEE (2)
Portland Area Hospitals
Financial Assistance
Policies and Procedures Discussion
Tuesday, September 12,
2000
PRESENT:
Kaiser Permanente Andee Petersen, Dan Remington
Legacy Health System Pamela Vukovich, Kathie
Dias
Portland Adventist Mark Perry, Kenneth Mitchell
Providence Health System Terry Smith, Teresa
Spalding, Ed Duran
Tuality Healthcare Tim Fleischmann, Jean Smith,
Jackie Nutt
University Hospital Aaron Crane, Debra Tomsen
Willamette Falls Tim Blanchard, Dawn Burns
OHAC Laura
Brennan, Ellen Pinney
OAHHS Ken Rutledge
AREAS OF BEST PRACTICES:
· Income
Guidelines
ú
Up to 150% of federal poverty level – full financial assistance
ú
150-200% of federal poverty level – reduced cost, affordable installment
ú
Greater than 200% of federal poverty level – case by case
ú
No asset included (liquid only)
ú
Every step to avoid bankruptcy
·
Cultural Accessible Policy
ú
Standard application
ú
Notification of financial assistance policy
ú
5th grade reading level
ú
Most frequently spoken languages based on local area
ú
Accessible to translation services
ú
Business cards and posters with specific telephone numbers (located in ER,
Admitting, Business Office, Day Care) in Size 12 Font and in multiple
languages
· Public
and Employee Awareness
ú
All staff be aware of policy and procedures
ú
Notice of availability with every bill with telephone number to call
ú
Available to anyone who asks
ú
Get consistency between brochure and policy
ú
Follow up and documentation important
ú
Included in admission forms
ú
Discounts on bills to cost for those individuals who qualify
· User
Friendly and Standardize Application
ú
Every opportunity to help individual complete application
ú
Pre-screening for OHP and other assistance programs
§
Help with application
ú
Assistance on completing application in other languages
ú
Coordinate and collaborate effort with neighborhood clinics (safety net
clinics) (standardize forms)
ú
Barriers
§
Small dollars – simplified procedure
§
More rigorous tests for larger dollar cases
ú
Train employees – practical Q&A on financial assistance
·
Collection and Lien Practices
ú
No interest charge or accruals including payment plan below 200% maybe
200-300%
ú
Six-month opportunity to apply before sent to collections
ú
60-day advance notice
ú
Send notices certified mail
ú
Clear credit history with those in collection if payment made or if new
financial assistance guidelines met after the fact
ú
No billing until decision made on application
ú
Include an appeal process
ú
Need flexibility due to changes in a person's situation
ú
No response or no payment made – OK to send to collection agency
ú
Establish work group on liens