Financial Assistance Policy

Johnston Health awards Financial Assistance based on the demonstrated need of the patient/ guarantor.

PURPOSE:

To further the mission of improving the health of the people in our community, Johnston Health provides financial assistance, as a payor of last resort, to qualified patients to facilitate their access to emergency and medically necessary health care services.

Johnston Health provides medically necessary emergency health care services to all people regardless of age, gender, geographic location, cultural background, physical mobility, or ability to pay for services.

POLICY:

Johnston Health awards Financial Assistance based on the demonstrated need of the patient/ guarantor.

Two methodologies may be used to determine the financial need of a patient/ guarantor:

  • Presumptive Financial Assistance Eligibility (Schedule 1 attached)
  • Financial Assistance Application Process (Schedule 2 attached)

Definition and explanation of each methodology is provided in the Financial Assistance Eligibility Schedules attached to this policy.

When making a Financial Assistance determination, Johnston Health will use the methodology that is most favorable to the patient/ guarantor.

PROCEDURE

 

Responsible Party Authority Level Procedure/ Process
Self-Pay Financial Counselor To act

 

 

  • Review Bad Debt Pre-List and identify accounts qualifying for Presumptive Financial Assistance
  • o After review and approval from Department Director (or designee) complete Financial Assistance adjustment
  • Explain Johnston Health Self-Pay and Financial Assistance program to every un-insured patient within 24 hours of admission/ ED visit
  • Assist patients requesting Financial Assistance in completion of Financial Assistance Application, Schedule 4
  • Perform initial evaluation of Financial Assistance request
  • o Compliance with eligibility guidelines
  • o Completeness of application
  • o Recommendation to approve or deny application
Administrative Director Patient Financial Services (or designee) To act

 

  • Review and approve Presumptive Financial Assistance Pre-Listing
  • Review all Financial Assistance applications
  • Approve/ deny applications from ≤$50,000
  • Recommend approval/ denial of applications >$50,000
CFO (or designee) To act
  • Review and approve/ deny Financial Assistance applications >$50,000
Financial Assistance Committee To act

 

  • Monthly, as needed, review denied Financial Assistance applications where patients have indicated desire to appeal decision and determine final disposition of application
  • Quarterly, review sampling of Financial Assistance applications to insure compliance with established guidelines

 

 Attachments

I. Scehdule 1: Presumptive Eligibility Criteria

II. Schedule 2: Financial Assistance Application Criteria

III. Schedule 3: Federal HHS Poverty Guidelines

IV. Schedule 4: Financial Assistance Application

REFERENCE

Schedule 1

PRESUMPTIVE FINANCIAL ASSISTANCE CRITERIA

There are occasions when a patient may appear eligible for Financial Assistance, but circumstances prevent a financial assistance application from being submitted or because documentation is lacking that would support the provision of financial aid. Such instances have resulted in a patient’s bill being assigned to a collection agency and ultimately recognized in the accounting records as a bad debt expense due to a lack of payment. This approach, however, results neither in a fair solution for the patient nor in an appropriate accounting of the transaction.

As a remedy to such situations, Johnston Health uses a Presumptive Financial Assistance scoring methodology that takes the following data into consideration to evaluate patient eligibility for Financial Assistance:

  • Patient residence
    • Home ownership (using tax record search)
    • Average size of home
    • Average cost in their particular zip code, street/neighborhood
  •  Average number of autos
    • Average cost
  • Average size of household for the community
  • Average income
    • Street
    • Community
  • Employment
  • Credit scores
    • Payment Tendencies
    • Available Credit

Johnston Health uses a presumptive scoring tool provided by Medlytix, which evaluates the ability to pay of un-insured patients. Based on the above criteria, all accounts are scored and classified as follows:

 

SCORE

ABILITY TO PAY

PROPENSITY TO PAY

   A

HIGH

HIGH

   B

GOOD

HIGH

   C

FAIR

FAIR

   D

POOR

LOW

   E

NONE

NONE

 

Johnston Health presumes accounts with a Medlytix score of D or E are not collectible and are to be deemed eligible for Financial Assistance when they aged for 120 days.

This presumptive eligibility, when properly documented, is sufficient to provide a charity care discount to patients who qualify.

The Charity Care Adjustment for Presumptive Charity Care Accounts will be as follows:

  1. Account Balance will be adjusted down to a $250 balance; the adjusted amount is the Presumptive Charity Adjustment
  2. The remaining $250 balance is written off to Bad Debt in order to protect Johnston Health’s right of future recovery

 

Schedule 2

FINANCIAL ASSISTANCE APPLICATION PROGRAM

Patients not eligible for Presumptive Financial Assistance may submit a Financial Assistance application to the Patient Financial Services Department for consideration of a Financial Assistance award.

Financial Assistance may be awarded if the applicant meets the following criteria:

  • Legal residency requirements
    • Citizen of United State of America; or otherwise legally residing in the United States of America, permanently or temporarily
    • Resident of Johnston County, North Carolina
  • Services for non-elective care, defined as care received in the emergency room or admission to the hospital resulting from an emergency room visit.
  • Patient has no available health insurance coverage
    • Unemployed and unable to financially afford private health insurance coverage
    • Employed (including self-employed), employer does not offer employee health insurance coverage and unable to financially afford private health insurance coverage
    • Ineligible for Medicare
    • Ineligible for Medicaid coverage, as demonstrated by documentation of denial
    • Ineligible for Medicaid coverage until Medicaid spend-down has been reached
  • Income falls within Federal Poverty Guidelines per attached Schedule 3.

Conditions disqualifying eligibility for Financial Assistance

  • Insured individuals, including
    • Non-traditional high-deductible health plans
    • Health savings accounts
    • Limited coverage health insurance plans
    • Individuals coverage health insurance plans Individuals who opt out of employer-sponsored health insurance coverage
    • Individuals who refuse to apply for Medicare, Medicaid, or any other government, non-government, or charitable program
    • Individuals who do not consent to allow Johnston Health to obtain credit report history from one of the major credit reporting agencies
  • Ancillary Services including, but not limited to:
    • Radiology
    • Laboratory
    • Wound Care
    • Urgent Care
  • Failure to submit the Johnston Health Financial Assistance Application form
  • Failure to provide supporting documentation for Financial Assistance Application

Non-Presumptive Financial Assistance is awarded on a case by case basis. Special circumstances will be considered as part of the review process and if deemed eligible for Financial Assistance may require exceptions to the above stated eligibility criteria.

 

 Schedule 3

FEDERAL HHS 2010 POVERTY GUIDELINES

Fed. HHS 2010 Poverty Guidelines Chart