Financial Assistance Policy

PURPOSE

To provide guidelines and procedures for Great River Medical Center and Great River Physicians and Clinics’ Financial Assistance Program.

POLICY

Great River Medical Center and Great River Physicians and Clinics are committed to providing financial assistance, also known as charity care, to persons who have health care 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. Consistent with our mission to empower our people to provide compassionate, high-quality care while being good stewards of our resources, we strive to ensure that the financial capacity of people who need health care services does not prevent them from seeking or receiving care. Great River Medical Center and Great River Physicians and Clinics will provide, without discrimination, care of emergency medical conditions to individuals regardless of their eligibility for financial assistance or for government assistance.

Accordingly, this written policy:

  • Describes services and service locations eligible under this policy
  • Includes eligibility criteria for financial assistance – free and discounted care
  • Includes criteria that could disqualify a patient from assistance
  • Describes the basis for calculating amounts charged to patients eligible for financial assistance under this policy
  • Describes where the financial assistance applications are located and the method by which patients may apply for financial assistance
  • Describes the relationship of this policy to our facility’s Billing and Collections Policy

OPERATIONAL DEFINITIONS

Financial assistance, also known as charity care

Healthcare services that have been or will be provided but are not expected to result in reimbursement or payment by the patient or other payers. Financial assistance results from a provider’s policy to provide healthcare services free or discounted to individuals who meet established criteria.

Family

Using the Census Bureau definition, a group of two or more people who reside together and who are related by birth, marriage, or adoption. According to the Internal Revenue Service rules, if the patient claims someone as a dependent on their income tax return, they may be considered a dependent for purposes of the provision of financial assistance.

Family income

Family income is determined using the Census Bureau definition, which uses the following income when computing federal poverty guidelines:

  • Includes earned income such as monthly gross wages, salary, and self-employment income
  • Unearned income such as unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the households, and other miscellaneous sources;
  • Non-cash benefits (such as food stamps and housing subsidies) are not considered as family income;
  • Is determined on a before –tax basis;
  • Excludes capital gains or losses; and
  • Income of spouses and all guarantors who are legally responsible for the costs of care will be considered
  • Does not include income of a family member under the age of 18 or attending high school.

Uninsured

The patient has no level of insurance or third-party assistance to assist with meeting his/her payment obligations.

Underinsured

The patient has some level of insurance or third-party assistance but still has out-of-pocket expenses that exceed his/her financial abilities.

Gross charges

The total charges at the organization’s full established rates for the provision of patient care services before the limitation on charges discount or other deductions from revenue are applied.

Limitation on charges

Total charges for patients with emergency or medically necessary care who qualify for financial assistance are limited to no more than the amounts generally billed to individuals with insurance coverage. Limitation on charges ONLY applies to Great River Medical Center services.

Amounts generally billed

An amount equivalent to the average amount billed to patients with insurance coverage, after insurance pays. The “look back” methodology was used in the determination of the amount generally billed percentage of 40 percent of total charges. This calculation was based on Medicare fee for service, Blue Cross Blue Shield, and commercial insurances actual fiscal year 2017 historical claims. This calculation is re-evaluated annually will be provided to individuals by request at no expense to the requesting party. Amounts generally billed ONLY applies to Great River Medical Center services.

Emergency medical conditions

Defined within the meaning of section 1867 of the Social Security Act (42 U.S.C. 1395dd).

Medically necessary

As defined by Medicare services or items reasonable and necessary for the diagnosis or treatment of illness or injury. This could also include elective services that are beneficial to the patient’s long term medical health. (This is at the discretion of Great River Medical Center and Great River Physicians and Clinics).

In order to manage its resources responsibly and to allow Great River Medical Center and Great River Physicians and Clinics to provide the appropriate level of assistance to the greatest number of persons in need, the Board of Directors establishes the following guidelines for the provision of financial assistance.

PROCEDURE

Services eligible under this policy

For purposes of this policy, “charity care” and “financial assistance” refer to health care services provided by Great River Medical Center and Great River Physicians and Clinics without charge or at a discount to qualifying patients. SEE EXHIBIT A for a listing of hospital services that are included or excluded from this policy.

  • Please note that services provided for non-medically necessary care that is considered elective and would not be covered by this policy may require prepayment as determined by Great River Medical Center or Great River Physicians and Clinics

Eligibility criteria for financial assistance

  1. Financial Assistance eligibility will be determined after a Financial Assistance Application has been completed and supporting documentation has been attached. A completed application will serve as documentation regarding the patient’s eligibility for assistance.
  2. The application MUST include the following information:
  • Family income. This includes earned income, unearned income, spousal income, etc. (See family income specifications above for clarification).
  • Number of dependents under the age of 18
  • Monthly expenses
  • Assets and liabilities may be used in the determination of eligibility in conjunction with family income information.
  1. Supporting documents such as pay stubs and tax returns MUST be included to support financial information reported.
  2. Financial assistance will be considered for individuals that are uninsured, underinsured, ineligible for government programs, or are unable to pay for medically necessary or emergency care based on their individual financial situation. Underinsured individuals include patients who have insurance or other coverage but their out of pocket expenses such as co-insurance, deductibles, and spend-downs exceed their financial abilities.
  3. Eligibility shall be based on an individualized determination of financial need, and shall not take in to account age, gender, race, social or immigrant status, sexual orientation, or religious affiliation.
  1. Financial assistance may not be considered for patients who qualify for assistance through government programs but do not complete the necessary actions needed to acquire government assistance. It is the patient’s responsibility to contact their local government agency to pursue assistance with government programs. A Medicaid denial letter (or similar agency document) is required before Great River Medical Center or Great River Physicians and Clinics will consider financial assistance for these individuals.
  • Financial Counselors are available to assist patients with enrollment in Medicaid and HealthCare Marketplace programs.
  1. Financial assistance is intended for residents for Great River Health System’s primary or secondary market service area. An exception could be made for any patient presenting with an urgent, emergent or life-threatening medical condition.
  2. It is preferred but not required that a request for charity and a determination of financial need occur prior to rendering of non-emergent medically necessary services. However, the determination may be done at any point in the collection cycle.
  3. Recurring financial assistance will be re-evaluated on a three-month basis
  4. Financial Assistance will be applied to all open balances with patient responsibility dates up to 3 months prior to the date of the assistance application approval and will include dates of up to 12 months from the date of the application approval.
  • Exceptions to this could include:
  1. Extenuating circumstances that could allow for financial assistance to extend beyond the 3 months prior to the application date and 12 months from the date of the application – this is at the discretion of Great River Medical Center and Great River Physicians and Clinics
  2. A change in financial circumstances which could cause a change in eligibility
  1. Patient payments in excess of $5 received prior to financial assistance determination including payments made 3 months prior to the date of the financial assistance application will be refunded to the patient up to the amount of the eligibility determination, which can be no more than the Amount Generally Billed. This does NOT include services provided at a clinic of Great River Physicians and Clinics.
  2. Great River Medical Center’s and Great River Physicians and Clinic’s values of human dignity and stewardship shall be reflected in the application process, financial need determination and granting of charity.
  3. Requests for charity shall be processed promptly and the Patient Financial Services - Patient Billing Department shall notify the patient or applicant of their qualification in writing within 30 days of receipt of a completed application.

Presumptive financial assistance eligibility

There are instances when a patient/individual may appear to be eligible for charity care discounts but there is no completed financial assistance form on file due to a lack of supporting documentation. Often there is adequate information provided by the patient or through other resources which could provide sufficient evidence to determine eligibility. Presumptive Financial Assistance is ONLY considered for balances related to services provided at Great River Medical Center. It is NOT considered for balances related to services provided at a clinic of Great River Physicians and Clinics.

1.Information is provided to Experian, our outside source, on a weekly basis. Experian returns results to us in regards to patient qualifications based on our Financial Assistance Policy.

2.Demographic and household information as well as credit scoring technology is used by Experian to determine the percent of assistance for which a patient may be eligible.

3.Great River Medical Center will attempt to contact patients based on their Presumptive Assistance qualification in order to allow the patient to apply for Financial Assistance.

4.Patients will NOT be disqualified from Financial Assistance based on Presumptive Assistance results if they have completed a financial assistance application with supporting documentation.

5.In the event the account is past due and there is no completed financial assistance application or supporting documentation the patient’s account could be considered for financial assistance based on the results received from Experian.

6.Presumptive eligibility can also be determined on the basis of individual life circumstances that may include:

  • State funded prescription programs
  • Homeless or received care from a homeless clinic
  • Participation in Women, Infants and Children program (WIC)
  • Food stamp eligibility
  • Subsidized school lunch program eligibility
  • Eligibility for other state or local assistance programs that are unfunded
  • Low income/subsidized housing provided as a valid address
  • Patient is deceased with no known estate
  • It is also acceptable to use proxy information to determine eligibility when income levels cannot be directly determined. Such information could include statements like “stays with friends” or “occasionally works”.
  • Patients who meet presumptive care guidelines may qualify for financial assistance discounts. This determination is at the discretion of Great River Medical Center.
  • In a situation, where presumptive eligibility is given to a patient and a financial assistance application is later obtained, the updated eligibility will be based on the financial assistance application with supporting documentation. In an event such as this, Great River Medical Center could adjust financial assistance up to three months prior to the application date.

Extenuating circumstances financial assistance eligibility

Occasionally there are extenuating circumstances which could cause the hospital to grant a charity care discount to patients who may otherwise not qualify for financial assistance under the above described criteria. An example would be if the patient had more medical debt in relation to income, resulting in an inability to meet their financial obligation. It is at the discretion of the financial assistance committee or the VP of Finance to grant charity discounts to patients with these extenuating circumstances.

Disqualification from financial assistance

  1. Failure to complete a Financial Assistance Application could result in disqualification
  2. Lack of supporting documentation
  3. No good faith effort by patient to apply for financial assistance after effort has been made by the Patient Financial Services-Patient Billing department to make the policy known
  4. Income is beyond guidelines that would qualify a patient
  5. Patient fails to follow through with governmental programs that are available to them
  6. Patient provides false documentation or information

Basis for calculating amounts charged to patients who qualify for financial assistance (ONLY APPLIES TO GREAT RIVER MEDICAL CENTER SERVICES)

  1. The Patient Protection and Affordable Care Act (PPACA) Sec. 9007(a)(5)(A) limits the amounts charged to patients who qualify for financial assistance for emergency or medically necessary care to no more than the amounts generally billed to individuals who have insurance coverage. Due to this requirement, uninsured patients who meet eligibility criteria specific to Great River Medical Center will receive an immediate Limitation on Charges discount of 60 percent of their total charges.
  2. The amount generally billed, which is the account balance after the limitation on charges discount, serves as the basis that the charity care discount will be applied for uninsured patients.
  • All patients eligible for financial assistance will not be charged an amount greater than the amount generally billed.

Example:

Patient account balance is $10,000. Patient has no insurance and qualifies for 50 percent financial assistance.

$10,000 x 60 percent = $6,000 (limitation on charges discount)

$10,000 - $6,000 = $4,000 (balance after limitation on charges discount)

$ 4,000 x 50 percent = $2,000 (financial assistance discount)

Account balance and patient responsibility = $2,000

  1. Services eligible under this policy will be made available to the patient on a sliding fee scale, in accordance with financial need, as determined in reference to Federal Poverty Levels (FPL) in effect at the time of the determination. This sliding fee scale will be updated on an annual basis as Federal Poverty Levels are updated.
  • Underinsured patients – Financial assistance will be based on the patient’s account balance after insurance
  • Uninsured patients – Financial assistance will be based on the patient’s account balance after the limitation on charges discount
  • Refer to EXHIBIT C for the financial assistance sliding fee scale

Method by which patients may apply for financial assistance

  1. A patient can apply for financial assistance by filling out the required Financial Assistance Application. The application is on online. It also is available at the following areas or provided to the patient in the following ways:
  • Offered to patients during Pre-Access
  • At registration or any Patient Access location
  • In the Emergency Department on registration or discharge
  • In the Patient Financial Services-Patient billing offices in the lobby next to the Gift Shop and on the lower level of Eastman Plaza.
  • By calling Patient Financial Services-Patient Billing at 319-768-3625, option 2
  • In all clinic offices locations
  • At the Burlington Department of Human Services office

Relationship to collection policies

  1. Great River Medical Center and Great River Physicians and Clinics management has developed policies and procedures for internal and external collection practices (including actions the health system may take in the event of non-payment, which includes collection action and reporting to credit agencies) that take into account the following:
  • The extent to which the patient qualifies for charity
  • Patient’s good-faith effort to apply for governmental programs
  • Patient’s good-faith effort to apply for Great River Medical Center’s and Great River Physicians and Clinics’ Financial Assistance Program
  • Patient’s good-faith effort to comply with payment agreements made with Great River Medical Center and Great River Physicians and Clinics
  1. Patients who qualify for financial assistance and who are cooperating in good faith to resolve their discounted hospital and clinic bills, Great River Medical Center and Great River Physicians and Clinics’ will do the following:
  • May offer acceptable payment plans that are within the guidelines of the Billing and Collection Policy
  • Will not send unpaid balances to outside collection agencies if consistent monthly payments will resolve the patient/guarantor financial obligation within the guidelines of the Billing and Collection Policy
  1. Great River Medical Center, Great River Physicians and Clinics, and agencies acting on their behalf will not impose extraordinary collection actions without first making reasonable efforts to determine if the patient is eligible for financial assistance under this policy. Reasonable efforts shall include:
  • Validating that the patient owes the unpaid bills and that all sources of third-party payments have been identified and billed by the hospital
  • Documentation that Great River Medical Center and Great River Physicians and Clinics have attempted to offer the patient the opportunity to apply for financial assistance pursuant to this policy and that the patient has not complied with the hospital’s application requirements.
  • Documentation that the patient has been offered a payment plan but has not honored the terms of that plan
  1. Great River Medical Center and Great River Physicians and Clinics will not send outstanding balances to an outside collection agency until 120 days from the date the balance became the patient’s responsibility have been exhausted
  2. Outside agencies acting on the behalf of Great River Medical Center and Great River Physicians and Clinics will not take extraordinary collection action until an additional 120 days have been exhausted.
  3. Extraordinary collection action includes but is not limited to the following:
  • Selling debt to a third party other than a collection agency
  • Reporting adverse information to a consumer credit reporting agency or credit bureau
  • Filing a claim for unpaid debt through the court system

Regulatory requirements

In implementing this policy, Great River Medical Center and Great River Physicians and Clinics management and facilities shall comply with all other federal, state and local laws, rules, and regulations that may apply to activities conducted pursuant to this policy. The Patient Financial Services-Patient Billing Manager is responsible for monitoring and evaluating compliance.

Approval levels for financial assistance:

  • Up to $5,000 – Financial Counselors, Credit Services Supervisor, Patient Financial Services Manager, Patient Financial Services Director, Home Health and Hospice Director
  • $5,000 – $10,000 – Credit Service Supervisor, Revenue Cycle Director or Home Health and Hospice Director
  • Over $10,000 - Financial Assistance Committee, Vice President of Finance

EXHIBIT A - Included and excluded services and department listings

INCLUDED

The following services are included when in relation to trauma/emergency care; a condition that if not promptly treated would lead to an adverse change in the health status of the individual, non-elective services provided in response to life-threatening circumstances in a non-emergency room setting, and medically necessary services.

  • All Inpatient Services
  • Day Hospital Services
  • Diagnostic Imaging Services (CT, MRI, Ultrasound, Nuclear Medicine, Mammography)
  • Digestive Health Services
  • Emergency Medical services
  • Heart and Vascular Services
  • Hematology and Medical Oncology Services
  • Laboratory Services
  • Obstetric Services
  • Radiation Oncology Services
  • Surgical Services
  • Wound Clinic Services
  • All Clinics of Great River Physicians and Clinics

Services evaluated on a case by case basis and at the discretion of Great River Medical Center – These services could be included or excluded from this policy based on the decision of Great River Health System’s Financial Assistance Committee:

  • Hospice and Home Health Services
  • Cosmetic Services
  • Elective Services
  • SNF
  • Rehabilitation Services (Note: Rehabilitation services unrelated to services provided by Great River Health Systems could be excluded)
  • Occupational Therapy
  • Physical Therapy
  • Speech Therapy
  • Business Health

DEPARTMENTS / CLINICS

Department Services of Great River Medical Center and clinics of Great River Physicians and Clinics listed below are included in this Financial Assistance Policy.

DEPARTMENTS

  • Acute Care Center Hematology and Oncology Radiation Oncology
  • Behavioral Health Unit Inpatient Dialysis Rehabilitation Unit
  • Cardiovascular Care Unit Intensive Care Unit Respiratory Care Services
  • Day Hospital Inpatient Pharmacy Sleep Disorders Center
  • Diagnostic Imaging Laboratory Surgical Services
  • Digestive Health Center Nursery Swing Unit
  • Emergency Department Obstetrics Unit Wound and Hyperbaric
  • Heart and Vascular Center Palliative Care

CLINICS

  • Cardiology Mental Health Surgeons
  • Eye Specialists Mt. Pleasant Orthopaedic Specialists Urology
  • Family Medicine Nephrology Wapello Clinic
  • Family Medicine, Mercy Plaza Orthopaedic Specialists West Point Clinic
  • Keokuk Clinic Presurgery Clinic Women’s Health
  • Mediapolis Clinic Pulmonology
  • Medicine Specialists QuickCare

HOSPITAL-BASED CLINICS OF GREAT RIVER MEDICAL CENTER

  • Hematology Oncology
  • Radiation Oncology
  • Wound and Hyperbaric

EXCLUDED

Services of Great River Medical Center and Great River Physicians and Clinics that are not included in this policy:

  • Residential Services (Klein Center)
  • Family Planning Clinic

EXHIBIT B - Billing and Collection Policy

Please refer to Billing and Collection Policy on our website.

View as Excel spreadsheet here.

Patient Responsibility
Family Size Poverty Level * 0% 25% 50% 75% Do not Qualify for Financial Assistance
1 $12,140 lower than $27,315 $27,316 $30,350 $30,351 $33,385 $33,386 $36,420 $36,421
2 $16,460 lower than $37,035 $37,036 $41,150 $41,151 $45,265 $45,266 $49,380 $49,381
3 $20,780 lower than $46,755 $46,756 $51,950 $51,951 $57,145 $57,146 $62,340 $62,341
4 $25,100 lower than $56,475 $56,476 $62,750 $62,751 $69,025 $69,026 $75,300 $75,301
5 $29,420 lower than $66,195 $66,196 $73,550 $73,551 $80,905 $80,906 $88,260 $88,261
6 $33,740 lower than $75,915 $75,916 $84,350 $84,351 $92,785 $92,786 $101,220 $101,221
7 $38,060 lower than $85,635 $85,636 $95,150 $95,151 $104,665 $104,666 $114,180 $114,181
8 $42,380 lower than $95,355 $95,356 $105,950 $105,951 $116,545 $116,546 $127,140 $127,141
% of Poverty Level 225% 226% 250% 251% 275% 276% 300% 301%
* Based on 2018 Federal Poverty Guidelines
NOTE: Patients whose family income exceeds 300% of the FPL may be eligible to receive discounted rates on a case-by-case basis based on their specific circumstances; such as, catastrophic illness or medical indigence. This discount is at the discretion of Great River Medical Center.
Revised 3/2018