SAMARITAN HOSPITAL PATIENT ACCOUNTS
Patient Accounts
Revised: 12/04/2015
CHARITY CARE
Chapter/Page #:
3-1
Definitions:
In this policy the terms “charity care” and “financial assistance” are used interchangeably. Based on the
American Institute of Certified Public Accountants (AICPA) Hospital Audit Guide, charity care
represents health-care services provided with no expectation that they will result in payment. Charity care
does not include bad debt or third-party contractual allowances.
Financial assistance is a reduction or elimination of the amount an individual owes for medical services.
Individuals will be considered for financial assistance based on their ability to pay charges for which they
are responsible, either because they do not have health insurance or because the charges are not eligible
for reimbursement from a third-party payer.
Policy:
Charity care or financial assistance for medically necessary health care services delivered at Samaritan
Hospital will be provided to individuals who meet certain financial criteria based on income, and family
size. Financial evaluations to determine eligibility for charity care or financial assistance will be offered
free of charge either before or after the provision of care.
1. Non-discrimination. This hospital shall render medically necessary services to all members of the
community who are in need of medical care regardless of the ability of the patient to pay for such
services. The determination of full or partial Charity Care will be based on the patient’s ability to pay
and will not be abridged on the basis of age, sex, race, creed, disability, sexual orientation or national
origin.
2. Charity Care Services. All available health care services, inpatient and outpatient, shall be available
to all individuals under this policy.
3. Determination of Eligibility. The determination of Charity Care should be made before providing
services. If complete information on the patient’s insurance or financial situation is unavailable at the
time of service, or if the patient’s financial condition changes, the designation of Charity Care may be
made after rendering services.
4. Confidentiality. The need for Charity Care may be a sensitive and deeply personal issue for
recipients. Confidentiality of information and preservation of individual dignity shall be maintained
for all who seek charitable services. Orientation of staff and the selection of personnel who will
implement this policy and procedure should be guided by these values. No information obtained in
the patient’s Charity Care application may be released unless the patient gives express permission for
such release.
5. Staff Information. All employees in patient accounting, billing, registration, and emergency areas
will have general knowledge of the Hospital’s Charity Care policy, and be able to direct questions to
the appropriate hospital representatives.
6. Charity Care Representative. The hospital shall designate an individual to process Charity Care
applications, coordinate outreach efforts, and oversee Charity Care practices.
7. Amounts Generally Billed. Those deemed eligible for a Charity Care discount will not be billed any
more than that which Medicare would pay.
8. Charity Care Limitation. Total annual Charity Care shall not exceed a level which will risk the
financial viability of the hospital.
9. Staff Training. All staff with public and patient contact are trained to understand the basic
information related to the hospital’s Charity Care policy and procedures and provide patient with a
brochure regarding the Charity Care Program. Appropriate hospital representatives will be trained in
assisting patients in the Charity Care process.
10. Uniformity. All facilities affiliated with this hospital will have identical Charity Care policies.
Application Process:
1. Application. The attached application will be used by patients to apply for Charity Care from the
hospital (Appendix A). Patients who do not have insurance may qualify for Charity Care based on
their monthly or annual income and their family size. Patients having insurance may also be eligible
for Charity Care for the portion of their bill that is not covered by insurance, including deductibles,
coinsurance, and non-covered services. Medicaid patients are not eligible for Charity Care for
deductibles and co-insurance due to Medicaid restrictions.
2. Application Assistance. The hospital’s Charity Care representative will provide application
assistance to patients. Translation services and assistance will be offered to all patients.
3. Requests for Information. The hospital shall send anyone who requests information on the hospital’s
Charity Care program a brochure (Appendix D).
4. Additional Requestors. Charity Care requests may be proposed by sources other than the patient,
such as the patient’s physician, family members, community or religious groups, social service
organizations, or hospital personnel. The patient shall be informed of such a request. This type of
request shall be processed like any other.
5. Timing. To be considered for Charity Care or financial assistance, individuals must complete the
financial evaluation form and return it to the hospital with the required supporting documentation
within 240 days after their initial bill. If available, a recent state Medicaid application may be used
instead of the financial evaluation form.
Determination of eligibility or denial of financial assistance will be communicated in writing to the
responsible party within 30 days of receipt of all required documentation. Lack of supporting
documentation, failure to complete all necessary information on the financial evaluation form, or
misrepresentation of any information may result in the denial of financial assistance. If application is
deemed to be incomplete, written additional instructions on how to complete the application, with
contact information, will be provided. Once on file, financial evaluation forms remain active for one
calendar year.
6. Supporting Documentation. Supporting documentation includes appropriate verification of income:
(1) the most recent Federal income tax return or Form 1722 from the Internal Revenue Service
confirming no tax return was filed; and/or (2) paycheck stubs from the last month indicating YTD
income, or a letter from employer(s) confirming income. Documentation exceptions may be made for
homeless patients.
Application Review Process:
1. Eligibility Criteria. Financial assistance will be offered on a sliding scale, based upon an evaluation
of the patient’s income and family size in comparison to the U.S. Department of Health & Human
Services Annual Poverty Guideline published in the Federal Register (Appendix B). Patients must be
ineligible for coverage by Medicaid to be considered for financial assistance.
If a patient’s income is below 100 percent of the annual poverty guideline, the hospital may offer
financial assistance of 80 percent of the charges. For patients with incomes between 100 and 150
percent of the annual poverty guideline, financial assistance will range from 60 percent to 70 percent
of the charges. Patients with incomes in excess of 100 percent of the poverty guideline will be
responsible for at least a portion of their personal liability.
Patients determined to be homeless, those indigent in a nursing home, and those deceased with no
estate, will be eligible for financial assistance for 100 percent of the charges, due to their
unrecoverable financial circumstances.
A summary sheet will be used (Appendix C) to summarize the financial assistance being provided,
and to indicate approval by appropriate staff.
Approval:
1. Approval Process. The completed application and related documentation will be reviewed and
approved by the business office manager, CFO, and CEO.
2. Approval Notification. The patient shall be notified in writing within thirty (30) days after receipt of
the properly completed Charity Care application and any supporting materials as to whether the
patient qualifies for the Charity Care Program.
3. Charity Care Likelihood. If there is reason to believe that the patient is eligible for Charity Care, i.e.,
the patient is uninsured, unemployed, and/or homeless, the patients’ record will be flagged and no bill
will be sent until the question regarding Charity Care eligibility is resolved.
4. Extraordinary Collection Actions. No ECA’s will be taken until reasonable efforts are made to
determine Charity Care eligibility.
5. Expired Patients. Patients who have died and have no estate are deemed to have no income for the
purpose of determining Charity Care eligibility.
6. Denial. If a patient is denied Charity Care, the patient shall be informed within thirty (30) days of the
denial. All reason(s) for denial shall be provided at that time.
Publication:
1. Publication Inside Hospital. Brochures (Appendix D) and signage will be located in Registration,
patient rooms, and Emergency Room to inform individuals about the financial assistance program and
how to apply. Information on the sign will be translated into languages appropriate to the
community.
Notification:
1. Patient Notification with Bill. On all bills sent to patients, a statement will be included regarding the
availability of various assistance programs including Charity Care and a contact number. This
information will be available at or below a sixth grade reading level. A plain language summary of
the policy will be provided at least 30 days prior to bring forwarded to a collection agency.
Collection Activity:
1. Restriction on Referral. Patients are not sent to collections without having an opportunity and
adequate time to develop an alternative payment arrangement. A copy of the hospital’s collection
policy will be made available to patients upon request.
2. Equitable Payment Schedule. In all instances, the hospital will make all efforts to work with the
patient to determine an equitable payment schedule considering the patient’s financial and medical
circumstances.
3. Charity Care Notification. Patients are not sent to collections before receiving at least 30 days
advance notice about the availability of Charity Care, related deadline for application, and adequate
time in which to apply for Charity Care. Accounts may be sent to collections only after 120 days have
passed from the first billing date for the service.
4. Charity Care Applications Completed After Extraordinary Collection Actions. When Charity Care
applications are received after going to a collection agency, the agency will be notified to cease
collection efforts. If the patient is deemed eligible, refund will be made of any over payment on
qualified balances, and any necessary actions will be reversed, such as credit agency reporting.
5. Prohibition on Medical Record Notation. No notations will be made in the patient’s medical record
regarding financial matters, including whether the patient paid all or part of any medical bill.
Recordkeeping:
1. Internal Recordkeeping. All Charity Care application will be logged in the Charity Care control log
and will be given a sequential control number. The completed applications will be kept on file for
seven (7) years. A copy of the patient’s Charity Care application and all correspondence with the
patient regarding the Charity Care application, approval, denial and appeal will be maintained in the
patient’s file.
2. Accounting. Charity Care shall be recorded using the direct write-off method and shall comply with
all accounting regulations by the American Institute of Certified Public Accounting.