ADMINISTRATIVE
TITLE
Financial Assistance Policy
NUMBER
NMG-PC-CC-701
JCAHO
FUNCTIONS
Continuum Of Care
APPLIES TO
Novant Medical Group Physicians Practices
I.
July 09
SCOPE / PURPOSE / POLICY STATEMENT
PPC1A-12: This policy
explains qualification
details for approval
for financial
assistance
Novant Health is committed to providing the best medical services to our community. In
keeping with its charitable mission, it is the policy of Novant Health to provide needed
medical care to citizens of the community, regardless of the patient’s ability to pay.
After verifying that the patient is not eligible for other public assistance programs (such
as Federal or State healthcare coverage, i.e., Medicaid, SCHIP, etc.), Novant Medical
Group, will apply discounts and/or Financial Assistance care based on the following:
• All Uninsured NMG Patients: patients whose annual family income falls below 300% of
the current year’s Federal Poverty Level Guidelines may be eligible for a 100%
reduction of patient. Pharmacy items/prescriptions are excluded. (Exhibit 1).
Patients whose annual family income is greater than 300% of current year Federal
Poverty Level Guidelines are eligible to receive a 20% discount to their balance. The
NMG Prompt Payment Policy may apply an additional 20% discount (total discount =
40%) to all charges if the balance for outpatient services is paid at the time of service.
Patients who have insurance coverage are not eligible for this discount. Pharmacy
items/prescriptions are excluded .
A patient’s eligibility may be determined prior to or after receiving services and is valid
for up to six months before the patient is required to reapply.
Patient accounts that meet financial assistance criteria but have account balances
placed with a collection agency in the previous six-month period should be returned to
the NMG CBO.
• All NMG Patients regardless of insurance status will be eligible for a Catastrophic
Discount if their outstanding balance places an unreasonable hardship in relationship to
their financial resources based on established criteria.
Eligibility Criteria – individuals considered for this program must meet all of the following
criteria:
A. The total NMG remaining account balance after insurance payments must be at
least $5,000.
B. The account has received the expected payment from the insurance company (if
applicable).
POLICY/PROCEDURE
NMG Financial Assistance
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ADMINISTRATIVE
C. The patient or responsible party does not have to be a State resident or U.S. citizen.
D. The patient or responsible party will receive and must complete a written financial
assistance application (see attachment) and provide all supporting data required to
verify eligibility.
E. The individual does not meet Financial Assistance requirements.
F. Discounts will apply to only medically necessary services. Elective procedures or
those not normally covered by insurance (plastic surgery, elective gastric bypass)
will not be eligible for this assistance.
G. Any account that has been submitted to bad debt for collection purposes will be
reviewed on a case-by-case basis.
H. The discounted amounts will be individualized based upon available financial
resources.
I.
Potential outcomes will include full payment, full write-off, and/or partial write-off with
agreed-upon payment plan.
J. Failure by the patient or responsible party to meet the obligations of the contract
within the agreed upon time frame will result in further collection action up to and
including referral to a collection agency. This action recognizes that some patients
have appropriate financial resources and that payment of their bills is an important
obligation
.
System Requirements
A. Upon approval, a discount will be applied manually to the patient’s account utilizing a
specific adjustment code.
EXCLUSIONS: This policy only applies to services rendered at Novant Health facilities
and does not apply to services rendered at non-Novant-affiliated physician practices or
by any independent physicians or practitioners. This policy also does not apply to
services provided within or outside the hospital/facility by physicians or other healthcare
providers including but not limited to Anesthesiologists, Radiologists, and/or
Pathologists, who are not employed by Novant. This policy does not apply to “elective
procedures” (including but not limited to cosmetic surgery).
II.
QUALIFIED PERSONNEL
NMG Office Staff
NMG CBO Staff
III.
EQUIPMENT
POLICY/PROCEDURE
NMG Financial Assistance
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ADMINISTRATIVE
None
IV.
PROCEDURE
The procedure serves as a guideline to assist personnel in accomplishing the goals of
the policy. While following these procedural guidelines personnel are expected to
exercise judgment within their scope of practice and/or job responsibilities.
Patients with limited financial resources and who do not qualify for State Medical Assistance
Programs may receive a discount on all services provided within a Novant Health physician
practices. The amount of patient responsibility is determined by poverty guidelines set forth by
the U.S. Department of Health and Human Services. The following procedure must be followed
in order to obtain approval.
Income Verification
The total family gross income at the date of application will be used to determine the patient’s
eligibility for Financial Assistance care. Income may be verified using applicants’ and coapplicants’ last two paycheck stubs, last two bank statements, a letter from employer indicating
pay, prior year W2 form, prior year 1040 form, or other means deemed appropriate by NMG.
AFDC or SSI for children will not be included in the family’s gross income. Applicants who have
no income must provide a statement of means indicating how they are paying for basic
necessities such as food, shelter, etc.
Family Unit includes husband, wife, and any children (including stepchildren) that live in the
home or are qualifying dependents for tax purposes.
• If the patient has not already applied for Medicaid coverage, the patient should be directed to
do so. In order to qualify for a discount, the patient must have been denied Medicaid coverage.
A copy of the Medicaid denial will be filed with the application.
• The patient must complete the Financial Assistance application (Exhibit 2) and return it with
the required documentation to the Practice’s Customer Service Navigator (CSN) for CBO
practices or the Manager/Administrator for non-CBO practices.
NMG CSNs/Practice Managers will be responsible for identifying eligible NMG patients for
Financial Assistance. Based on the recommendation of the practice and meeting of eligibility
requirements, NMG CBO Management will be responsible for approval of NMG financial
assistance applicants.
• The NMG CSN/Practice Manager will review the application and supporting documentation
and forward all to the NMG CBO Financial Assistance Care Supervisor. A copy of all documents
should be filed at the practice. Final approval will be determined by the NMG CBO. Patients will
be notified by a NMG CBO CSN/Practice Manager of their eligibility, the amount of the write-off
and the remaining amount due. The patient is responsible for the full amount of the patient
account balance remaining after the deduction is applied. It is the responsibility of the NMG
CBO CSN is to enter the Financial Assistance Care into the practice management system with a
coverage termination date of six months past the date of approval for CBO Practices. The NMG
CSN will also notify the practice of the patient’s approval. The practice manager is responsible
for these activities for non-CBO practices.
• Patients who incur hospitalization charges by NMG Providers and subsequently do not present
to the NMG practice for follow up care will be deemed indigent/homeless and automatically
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NMG Financial Assistance
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ADMINISTRATIVE
qualify for Financial Assistance Care under all the following conditions. The patient is unable
to be contacted by address, telephone, or skip tracing methods. It has been verified that the
patient is not eligible or a current recipient of Medicaid.
V.
DOCUMENTATION
VI.
DEFINITIONS
NMG – Novant Medical Group
CBO - Central Billing Office
VII.
RELATED DOCUMENTS
Exhibit 1
Exhibit 2
VIII.
REFERENCES
IX.
SUBMITTED BY
Kelly Baker, Senior Director, NMG CBO
X.
KEY WORDS
Financial, Assistance, CBO, Charitable
XI.
INITIAL EFFECTIVE DATE
DATES REVISED
DATES REVIEWED
POLICY/PROCEDURE
07/01/09
NMG Financial Assistance
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ADMINISTRATIVE
Exhibit 1
2009 Guidelines - Income as a % of Poverty
Level
Persons in Family or Household
48 Contiguous
States and D.C.
300%
(100% Discount)
All Patients
1
$
10,830
$
32,490
2
$
14,570
$
43,710
3
$
18,310
$
54,930
4
$
22,050
$
66,150
5
$
25,790
$
77,370
6
$
29,530
$
88,590
7
$
33,270
$
99,810
8
$
37,010
$
111,030
$
3,740
$
3,740
For each additional person, add
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NMG Financial Assistance
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ADMINISTRATIVE
Exhibit 2
Financial Assistance Application
Today’s Date:____________________
Do you have medical insurance including Medicare and/or Medicaid? _______ If yes, name of insurance____________________
I. Patient Demographics
Patient Name:__________________________________________________________________________________
(Last) (First) (Middle) (SSN) (DOB)
Guarantor’s Name:_____________________________________________________________________________
(Last) (First) (Middle) (SSN) (DOB)
Address:______________________________________________________________________________________
(Street) (City) (State) (Zip Code)
___________________
(Phone Number)
II. Household Information
Marital Status (Circle One): Married Single Separated Other__________
How many people live in your home (including yourself, spouse and children)? ________________ List names & relationship on the back of this
form.
III. Employment/Income
Are you employed? -____________
Employer: -______________________ Occupation:_____________________ Length of Employment:_______
If married, is your spouse employed? __________Employer:_______________________
Occupation:_____________________ Length of Employment:________
Monthly Income
Employment
Social Security
Unemployment
Child Support/Alimony
Other ______________
Applicant
Spouse
Total Monthly Income ______________________________
Act Number(s)_________________________
I certify that the information provided is true and to the best of my knowledge. I understand that fraudulent or misleading information will make me ineligible
for any financial assistance. I authorized the release of any information needed to verify the information provided and for billing and collections in compliance
with applicable federal and state laws. Proof of income may be required before any consideration is made. Acceptable proof of income may be, but not limited to:
copy of paycheck stubs, copy of last year’s tax return, or letter from employer stating present salary and hours worked.
Signature of Patient/Guarantor
Date
Office Use Only
Signature of Interviewer____________________________________ Date ____________________
Administrative Signature ___________________________________ Date ____________________
Approved _________________ Percentage _____________
Comments_____________________________________________________________________________
POLICY/PROCEDURE
NMG Financial Assistance
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ADMINISTRATIVE
PROCEDURE SIGNATURE SHEET (one copy only to be maintained by author)
Company / Facility(s)
Novant Health
Department
Novant Medical Group
Procedure
Financial Assistance Care
Action
Approved
PROCEDURE APPROVED BY:
Title
Approved By
Signature
NMG Chief Operations Officer
Michelle Grier
04/16/09
NMG CBO, Senior Director
Kelly Baker
06/01/09
Committee
Chairperson/Designee
Date
NMG Practice Standards Committee
John Card, MD, Chairman
07/02/09
Date
COMMITTEES APPROVED BY:
DATES OF APPROVAL:
Date Revised
07/2009
Date to be Reviewed
07/2012
POLICY/PROCEDURE
NMG Financial Assistance
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