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Financial Assistance Policy

To establish guidelines and procedures for identifying patients who are under or uninsured by insurance or other third-party payers and who are unable to pay for some or all of their healthcare services due to genuine financial need.
Delta Memorial Hospital (DMH) offers several ways to help patients with their medical bills:
• Sliding scale discounts based on income levels
• Point of Service payment discounts for uninsured and underinsured
• Payment plan options
• Assistance in applying for government assistance programs.
1. Charity care means inpatient and outpatient medical treatment and diagnostic services for uninsured or underinsured patients who cannot afford to pay for the care provided. Charity care does not include bad debt or contractual adjustments, but it may include co-payments or deductibles, or both.
2. Bad Debt is defined as expenses resulting from treatment for services provided to a patient, who, having requisite financial resources to pay for health care services, has demonstrated by his/her actions an unwillingness to comply with contractual arrangements to resolve a bill.
DMH is committed to providing financial assistance to persons who have healthcare needs and are uninsured, underinsured, ineligible for a government program, or otherwise unable to pay, for medically necessary care based on their individual financial situation. The Financial Assistance Policy is designed to allow relief of all or part of the charges that exceed a qualifying patient's reasonable ability to pay. Patients who do not qualify for state or federal assistance and are unable to establish partial payment or pay their balance in full will be considered for financial assistance.
Financial Assistance is not considered to be a substitute for personal responsibility. Patients are expected to cooperate with DMH's procedures for obtaining financial assistance or other forms of payment, and to contribute to the cost of their care based on their individual ability to pay. Individuals with the financial capacity to purchase health insurance are encouraged to do so, as a means of assuring access to health care services, for their overall personal health, and for the protection of their individual assets. Patients or the patient's guarantor are required to provide documentation to qualify for financial assistance which demonstrates the patient's income or assets are insufficient to pay for their care. Patients or their guarantors are expected to assist with all such efforts to obtain third-party payments. Verified dually eligible Medicare and Medicaid patients qualify for indigent care without completing a financial assistance application. These dually eligible accounts are also eligible for inclusion on the Medicare Bad-Debt cost report. Medicaid beneficiaries that acquire Medicaid under SLMB, Family Planning Services, and/or have exhausted days automatically qualify for indigent care without completing a financial assistance application.
Delta Memorial Hospital will provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility for financial assistance or for government assistance.
This Financial Assistance Policy sets out DMH's practices regarding offering of discounts and charity care to qualifying patients for charges of DMH, Delta Health Services, and River Valley Medicine (DMH cannot offer financial assistance for the charges of any private physician practices, including those offering services at DMH) by:
1) Describing the eligibility criteria for financial assistance and circumstances in which a patient may qualify for free or discounted care;
2) Describing the basis for calculating amounts charged to qualifying patients and how the discounts will be applied;
3) Limiting the amount that DMH will charge qualifying patients for emergency or other medically necessary care to the same amount of that charged to individuals who have insurance coverage;
4) Describing the process for applying for financial assistance;
5) Describing the process used by DMH to publicize this policy within the community it services; and,
6) Describing the actions DMH will take in the event of non-payment.

Eligibility Criteria for Financial Assistance
DMH staff shall attempt to identify those patients in need of financial assistance at the time of registration. The patient's insurance information and/or payment arrangements shall be discussed before services are rendered, except in the case of emergency services in accordance with EMTALA regulations. Patients requiring emergent or urgent medical care and pregnant women in active labor shall be treated without regard to their ability to pay in accordance with EMTALA regulations.
DMH will provide a copy of the plain language summary document of the Financial Assistance Policy to all uninsured patients at the time of registration. The patient will be required to sign the document to be scanned into DMH's document imaging system for each encounter. This will document that the patient was made aware of the Financial Assistance Policy. Patients, identified as needing financial assistance shall be encouraged to complete the financial assistance application.
The following classes of patients may qualify for financial assistance:
a. Under insured patients
1. Those patients who have some form of third party payer coverage for health care services, but such coverage is insufficient for pay the current bill.

b. Uninsured patients
1. Those patients who have no third party payer coverage for health care services and have advised they are unable to pay their account balances. Uninsured patients may request financial assistance at any time during pre-registration, registration, inpatient stay, or throughout the course of the billing and collections cycle by requesting and fully completing an application for financial assistance.

Financial Assistance Calculation and Application
All patients who are able will be expected to pay for their own health care services to avoid shifting the burden for their care to other patients and the general public. The Financial Assistance Policy should have no impact on the collection policies and practices with regard to those balances that do not qualify for financial assistance. Failure to honor payment arrangements on amounts exceeding any financial assistance adjustments may result in the total financial assistance being revoked.
• Any patient of DMH, Delta Health Services, or River Valley Medicine (both rural health clinics owned and operated by DMH) has the right to apply for financial assistance regardless of where they live or their income status.
• Fees for services at DMH will be discounted based on family size and the family's average gross monthly income for the period the financial assistance is requested. Federal Poverty Guidelines for Arkansas per the Federal Register will be the only criteria used for the application of this policy. Financial assistance consideration is given for patients with incomes less than 200% of the Federal Poverty Guideline for their family size.
• Patients with third party resources recoverable by DMH (i.e., Medicare, Medicaid, private insurance, etc.) may still be eligible for financial assistance on the balance the third party does not cover. Before an application is submitted, all other possible resources must be exhausted.
• Patients will be required to execute a DMH Promissory Note at the time of service indicating a commitment to pay the balance of the fees after any third party payments and any discounts they are determined eligible are applied.
• Income must be reported for all members of the applicant's household.
• The application must be filled out completely and returned to the Business Office Manager with all required income verifications and appropriate documentation.
• Financial assistance adjustments will not apply unless all requested materials have been obtained within 90 days of office visit or date of payment from third party.
• Income verification may include:
o Paycheck stub showing gross income earned by all members in household for the year the sliding scale fee is being applied for. If an individual cannot produce documentation verifying income, they will be allowed to bring a letter from their employer on company letterhead and signed by the employer stating their gross annual income.
o Unemployment check stub.
o Social Security check stub.
o Letter of award from Social Security, welfare, or the like.
o Copies of the previous year tax return for all wage-earning household members.
• Approved applications are valid for the visit(s) in which they are applying and for three months following the approved application.
• Patients should allow 7 business days for the review process. The Business Office Manager will notify the patient/responsible party of their determination by letter. Patients may receive a bill before the end of the month showing the full amount charged. Their reduced rate will appear on an updated bill if they qualify.

Application Process
Financial assistance is available to people who are uninsured or underinsured, and who cannot pay for their care, based on financial need (details on how financial need is decided are in this policy). Financial Assistance is based on each person's situation, and will not take into account age, gender, race, social or immigrant status, sexual orientation or religious affiliation. Services eligible under this Policy will be made available to the patient on a sliding fee scale, depending on financial need, as determined by Federal Poverty Levels (FPL) in effect at the time of the request/decision. Referral of patients for Financial Assistance may be made by any member of the DMH staff or medical staff, including physicians, nurses, financial counselors, registrars, social workers or case managers. A request for Financial Assistance may be made by the patient or a family member, close friend, or associate of the patient, subject to applicable privacy laws. Requests can be made prior to, during or after medical service has been provided.
Financial Assistance will be calculated based on a sliding scale method that is updated annually within the DMH Business Office. To be eligible, the patient must do the following:
1. Complete and submit a Patient Financial application with supporting documents or internal verification.
2. Patient/household must meet DMH's Financial Assistance guidelines.
i. They must meet a financial need requirement determined based on an individual review and may include:
1. An application process. The patient or the patient's sponsor may be required to supply personal, financial and other relevant information with supporting documents;
2. The review of publically available data that provide information on a patient's or patient's guarantor's ability to pay (like credit scoring and tendency to pay evaluations);
3. Reasonable efforts by DMH to find other sources of payment and coverage from public and private payment programs. Reasonable efforts may be made to help patients apply for these programs;
4. Taking into account the patient's available assets and all other financial resources available to the patient; and
5. A review of the patient's unpaid bills for prior services and the patient's payment history.
3. Identify unusual medical expenses or tragic events on the Patient Financial Profile.
i. For the purpose of non-discriminatory assessment, DMH will consider the household income.
4. The referring/attending physician must determine when patient services are medically necessary.
Once the above requirements have been met, the following will happen:
• A final decision will be made within seven (7) calendar days.
• The Financial Assistance decision will be valid and useable for the accounts listed at the time of application and for three (3) months after approval. Patients should inform Business Office Manager of any new accounts during the three month time frame after approval to ensure all accounts have the discount applied.
• Financial Assistance will be available based on best available information after all efforts to contact the patient and obtain financial information have been exhausted. The decision may be made during the collections process if efforts to collect information are exhausted at that time.
• It is preferred, but not required, that a request for Financial Assistance and a determination of financial need happens before any pre-scheduled non-emergency medically necessary services. The need for Financial Assistance may be re-evaluated at a later time or when more information related to the eligibility of the patient for Financial Assistance becomes known.
• It is the responsibility of DMH Registration/Business Office staff to give all necessary information and paperwork for Financial Assistance to all eligible patients. The Business Office Manager is responsible to ensure all necessary criteria are met, the allowance is given and the adjustment is processed. Adjustment approval threshold levels are identified on the Financial Assistance application worksheet. All documents pertaining to Financial Assistance are maintained by the Business Office Manager within the Business Office..
• If a patient cannot make a substantial payment or commit to a payment plan to resolve their approved discounted medical bill, all elective and non-urgent hospital procedures and related services may be deferred.
• Falsification of information, lying, or incomplete documentation from the patient or responsible party could result in a denial of Financial Assistance.
• Having said all of the above, the amounts charged for emergency and necessary medical services to patients who are eligible for Financial Assistance under this Policy will not be more than the amount generally billed to individuals with insurance covering the same care.
Reasons for Denial: DMH may deny a request for financial assistance for a variety of reasons including, but not limited to:
• Sufficient income.
• Sufficient asset levels.
• Patient is uncooperative or unresponsive to efforts to work together.
• Requests for care when there is no identifiable means of obtaining long-term support (e.g., medication or implantable devices) needed to sustain the initial successful outcomes of care
• Incomplete Financial Assistance application despite reasonable efforts to work with the patient.
• A pending insurance or liability claim that could be a source of payment.
• Withholding insurance payment and/or insurance settlement funds, including insurance payments sent to the patient to cover services provided by DMH, and personal injury and/or accident related claims.
Communication of Financial Assistance Availability
a. Notices will be posted in key areas, including Admissions and Emergency Department advising patients that DMH provides financial assistance. Such notices will contain instructions on how to obtain a free copy of the Financial Assistance Policy and application form.
b. Current and complete copies of the Financial Assistance Policy and application form will be available on DMH's website along with a plain language summary of the policy.
c. Plain language summary copies of this policy will be distributed to the local DHS office.
d. Written information regarding this Financial Assistance Policy will be provided to all patients who request the information, whether at admission or any other time.
e. DMH will ensure that front-line staff are able to answer questions regarding this Financial Assistance Policy effectively or direct such inquiries to the appropriate department.
Actions in the Event of Non-Payment
DMH will make reasonable efforts to ensure that patients are billed for their services accurately and timely. DMH will attempt to work with all patients to establish suitable payment arrangements if payment in full cannot be made at the time services are provided or upon the first patient bill being delivered to the patient. Typically, patients will receive their first statement within 45 days of discharge from the facility.
DMH has established a self-pay fee schedule to consistently discount uninsured patient bills. If a patient is uninsured and does not qualify for program assistance through DMH's financial assistance program, the patient will be registered as self-pay.
A. Patient Billing Notices and Timeframes
a. Patients will receive their first statement within 45 days of discharge from DMH.
b. The first three statements will include an overview of DMH's Financial Assistance Policy that will contain information about the program, contact information for DMH's financial assistance team, where to obtain a copy of this Financial Assistance Policy free of charge.
c. Uninsured patients will not be referred to DMH's collection agency for follow-up in less than 120 days from the date of the first statement. Patients will be allowed to request financial assistance up to 240 days from the date of the patient's first statement, or any time during the collection process.
B. Extraordinary Collection Actions (ECAs)
a. DMH contracts with Trubridge and Mid-South Adjustment Company, Inc. for its patient and/or guarantor collection processes, to include pre-collection agency follow up and bad debt collection agency placement. DMH patient accounts are subject to the following ECAs:
i. Placement with collection agency;
ii. Credit bureau agency reporting;
iii. Placing a lien on property;
iv. Attaching or seizing a bank account or other personal property;
v. Commencing a civil action; and/or
vi. Garnishing wages
b. If during the course of collections follow-up, a patient or guarantor requests financial assistance or indicates that they are uninsured and cannot pay for their care, they will be referred to DMH's financial assistance team to be screened for potential financial assistance eligibility. If it is determined a patient may be eligible for assistance, collection activity will continue until the patient returns the appropriate application. Once the application is received, regardless of completeness, all further collection activity will be stopped pending a decision from the financial assistance team on assistance eligibility.


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