2016 Experian Information Solutions, Inc. All rights reserved. Experian and the marks used herein are service marks or registered trademarks of

Transcription

1 2016 Experian Information Solutions, Inc. All rights reserved. Experian and the marks used herein are service marks or registered trademarks of Experian Information Solutions, Inc. Other product and company names mentioned herein are the trademarks of their respective owners. No part of this copyrighted work may be reproduced, modified, or distributed in any form or manner without the prior written permission of Experian. Experian Public.

2 Introducing: Becky Peters Sutter Health Kim Berg Experian Health 2

3 Automating Financial Assistance with powerful data and analytics

4 Patient Financial Clearance Solution Overview Confidently determine the appropriate financial pathway for every patient in real time. Meet 501r regulatory requirements, reduce AR days and increase point-ofservice collections. Identity patients who qualify for Medicaid, charity and other financial assistance programs and auto-enroll eligible patients. Assess a patient s likelihood to pay medical bills to drive financial counselling discussions. Calculate optimal payment plan amounts for each patient. How do your financial clearance statistics measure up? 20% High deductible health plans grew from 4% to 20% from % Percentage of default payment plans at many healthcare organizations. 87% Percentage of individuals who enrolled through Healthcare.gov that qualified for financial assistance. $42,000,000,000 Uncompensated Care Costs 4

5 Objective Understand requirements of Code Section 501(r) Share tools for establishing necessary procedures Share implemented strategies that ensured compliance and promoted the hospital s charitable purposes and other mission objectives 5

6 501(R) Overview What it means for you? Section 501(r) was added to the IRS code by the Patient Protection - Affordable Care Act (PPACA) and imposes new regulations on 501(c)(3) organizations that operate one or more hospital facilitiies. Four duties for code 501(c)(3) hospitals underaffordable Care Act: Community Health Needs Assessment (CHNA) Financial Assistance Policy (FAP) Limitation on Charges (AGB) Billing and Collection Requirements (ECA) ECA CHNA 501(R) FAP AGB 6

7 Impact Failure to follow regulations may result in the revocation of a hospital s non-profit, 501(c)(3) status. 7

8 We started with creating a FAP Policy Dashboard 8

9 Financial Assistance Policy and Emergency Medical Care Policy The final regulations require: Hospital facility s FAP to list the providers, other than the hospital facility itself, delivering emergency or other medically necessary care in the hospital facility and to specify which providers are covered by the hospital facility s FAP and which are not. Specify eligibility criteria for financial assistance, including whether such assistance includes free or discounted care; The method for applying for financial assistance; Final regulations state that a hospital may grant FA notwithstanding an applicant s failure to provide such information. Hospital may grant FA based on evidence other than that described in the FAP application or attestation by the applicant. The actions that the hospital may take in the event of nonpayment (for those facilities that do not have separate billing and collections policies); The measures to publicize widely the FAP within the hospital s community it serves (website, paper copies available, displays). Requires that the FAP be made available in English and in the primary language of any population with limited proficiency in English that constitutes more than 10% of the residents of the community served by the hospital. The facility must provide a paper copy unless the individual indicates they prefer to receive or access the document electronically. Requires that a conspicuous public display reasonably calculated is placed in a location where visitors/patients are likely to see it. With respect to the emergency medical care policies, these regulations mandate that hospitals must provide, without discrimination, care for emergency medical conditions within the meaning of the Emergency Medical Treatment and Labor Act (EMTALA). 9

10 Sutter Health Category Changes Financial Assistance Category 2015 Policy 2016 New Policy Full Charity Care Available Available Partial Charity Care Available Eliminated Special Circumstance Charity Care Available Catastrophic Charity Care Available Eliminated High Medical Cost Charity Care Available Available Benefits exhausted during inpatient stay only (More information on next slide) Uninsured Patient Discount Available Moved from FAP policy to Hospitals Billing and Collection Policy Uninsured Prompt Payment Discount Insured Prompt Payment Discount Available Available Moved from FAP policy to Hospitals Billing and Collection Policy Eliminated 10

11 Sutter Health Special Circumstance Options Special Circumstance Bankruptcy Patients Homeless Patients Deceased Patients Medicare Patients Medi-Cal Patients Benefits exhausted during inpatient stay only Available options for situation Will not qualify for charity care, but rather a bankruptcy write off May be evaluated under Full Charity Care guidelines May be evaluated under Full Charity Care or High Medical Cost Charity Care guidelines May be evaluated under High Medical Cost Charity Care guidelines May be evaluated under High Medical Cost Charity Care guidelines (Excluding Medi-Cal Share of Cost) May be evaluated under High Medical Cost Charity Care guidelines (Qualifying amount after insurance contractual adjustments) 11

12 Sutter Health Criteria Changes 2015 Policy 2016 New Policy Varies between Hospitals Full Charity Care Federal Poverty Level (FPL) thresholds vary between facilities and regions from 200% to 400% Partial Charity Care FPL thresholds vary between facilities and regions from 201% to 500% Standard for all Hospitals Full Charity Care: Uninsured patient with family income at or below 400% of the FPL; Full write off of all hospital charges High Medical Cost Charity Care: Insured patient with family income at or below 400% of the FPL and family medical expenses incurred in the past 12 months exceed 10% of the patient s family income; Full write off of all patient responsibility 12

13 Sutter Health Determination Changes 2015 Policy 2016 New Policy Approval valid for single facility/region only Approval is valid for all Organization hospitals Charity care approval length not written in policy Once approved, patient is presumed eligible for Financial Assistance for a period of one year (we can revalidate throughout the approval year though) 13

14 Sutter health Other Key Policy Highlights Financial Assistance Information and Application will be available in 26 languages The policy, plain language summary and the financial assistance application will be available in all translated languages on the Sutter Health website ( at the Hospital registration areas and by calling the Contact Center at

15 Widely publicizing the FAP 15

16 Extraordinary Collection efforts ECA - Billing and Collections Harsh examples of the use of collection agencies by charitable hospitals provided Congress with the impetus to enact Section 501(r). As a result, Section 501(r) (6) specifies that hospitals must make reasonable efforts to determine whether individuals are FAP-eligible prior to engaging in extraordinary collection actions or ECA. Reporting of adverse information to credit agencies as an ECA Liens are not ECA Debt sales are ECA, however there are exceptions further described in the final rules Preservice collection is not ECA 16

17 Sutter health Other Key Policy Highlights Financial Assistance is not available when Uninsured Patient seeks Complex/Specialized Services Medi-Cal Patients with Share of Cost Patient declines covered services Insured patient does not cooperate with third-party payer (For example, patient does not supply coordination of benefit or accident information requested by insurance company) Payer pays patient directly Information falsification Third party recoveries Professional (physician) Services 17

18 Reasonable Efforts to Determine FAP Eligibility In short, a hospital will be deemed to have made reasonable efforts if it: Notifies the individual about the FAP; Assists the individual who has submitted an incomplete FAP with relevant information to fully complete it; and Upon receipt of a properly completed FAP application, makes and documents a determination as to whether the individual is FAP-eligible. Sutter Health utilizes Experian Charity Advisor to review all Self Pay accounts for Financial Assistance eligibility. Incomplete FAP applications require hospital to suspend ECA s until either the individual completes the FAP application and the hospital facility determines FAP eligibility or until the individual has failed to respond to requests for additional information/documentation within the reasonable period of time. Clarified that a claim in a bankruptcy proceeding is not an ECA Clarified that if a facility believes an individual may qualify for Medicaid, the hospital may postpone maki. ng an FAP-eligibility determination until after the individual s Medicaid determination has been finalized. 18

19 Sutter Health Collaborative efforts Financial Assistance & Government Programs Screening for Medical Coverage Pre-Service and Onsite Patient Advocates available to assist patients with FAP at all service points (ED, Pre-Reg, Patient Access) Dedicated Telephone Number to assist with Government Programs Screenings for potential coverage under a County, State, or Federal program Timely identifications of self pay accounts in EPIC and immediate verbal communication to expedite FAP determination Experian Real Time FAP software utilized to determine eligibility Accounts pre-screened again for FAP prior to bad debt assignment Reasonable Efforts to Determine Eligibility (FAP AND MEDICAID) EPIC WORKQUES 19

20 Sutter Health how we manage our progress FINANCIAL ASSISTANCE POLICY Utilize Experian s Charity Advisor to review all Patient Liability balances prior to sending to Early out of Bad Debt for Financial Assistance Eligibility. Evaluate / track Charity Care write offs through a Revenue Cycle Pulse Report reports charity care write offs in addition to providing a summary by week/month Review write offs for Charity Care in relation to bad debt expense; should see it decrease as charity increases; total Uninsured Discounts should be decreasing with more patients being insured or converted to Medicaid. 20

21 Best Practice - COMPLIANCE DESIGN Sutter implemented a banner flag in EPIC to identify patients that qualify for Charity Care Revenue Cycle Pulse Report includes Charity tracking Collaborative partner available at all entry points: Preservice, POS, Post Discharge, and onsite in the ED to assist with our Automated Financial Assistance eligibility review through Experian and/or assisting with filing Medicaid/Government Programs applications. Developed a dedicated team for soft transfers when a patient may qualify for Medicaid or a Government Program. A live person is always available to assist with questions or calls to quickly identify potential linkage. 21

22 Questions? 22

23