Financial Assistance Policy

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PURPOSE:

To define eligibility, application and approval processes for Financial Assistance. Financial Assistance is offered to uninsured, underinsured, and medically indigent patients who indicate an inability to pay for emergency and other medically necessary care provided at Vanderbilt University Medical Center.

SCOPE:

This policy is applicable to patients receiving Eligible Health Care Services at VUMC.

DEFINITIONS:

Click here for definitions of terms used within the Financial Assistance Policy.

POLICY:

I. Introduction
II. Eligibility Criteria
III. Basis for Calculating Patient Charges and Amounts Generally Billed
IV. Method for Applying for Financial Assistance
V. Actions that may be taken in the event of nonpayment
VI. Use of Extraordinary Collection Actions
VII. Eligibility information obtained from other sources
VIII. Other Information

I. Introduction

VUMC is committed to providing Eligible Health Care Services regardless of a patient’s ability to pay.  Patients who demonstrate an inability to pay and who meet this policy’s financial criteria for qualification will be covered under the Financial Assistance Policy.  Patients are informed of VUMC’s Financial Assistance Policy primarily through the VUMC website, Financial Counselors, Admitting and ED Registration staff, Patient Financial Services Customer Service, signage, and brochures distributed in VUMC clinic and hospital locations. The website information is listed on all billing statements with a link to a plain language summary of this policy.  For patients without internet access, this policy is available when calling VUMC Patient Financial Services.  These communications are available in English, Spanish, and Arabic.  

II. Eligibility Criteria

VUMC utilizes four possible methods for determining if an uninsured or underinsured patient is eligible for Financial Assistance.  The first is participation in state assistance programs (Medicaid).  Patients who are eligible for TennCare or other state Medicaid programs are automatically qualified for a 100% discount without further investigation.  The remaining processes available for determining eligibility for charity are: an Application Process, an External Screening Process, and an Alternate Charity Process.

In the Application Process, patients complete an electronic or paper form and provide documentation to support the patient’s income and family size. VUMC may also supplement the application with data received in the External Screening Process to validate information received in the Application Process. Uninsured patients with balances above $250K will be proactively contacted by VUMC within 45-days of the first statement to attempt to get a long form application.    

VUMC uses an External Screening Process to determine estimated income and family size for the purpose of determining charity care eligibility and potential discount amounts. The External Screening Process provides a systematic method to grant financial assistance to patients with appropriate financial needs by providing VUMC with an estimated income and family size for the patient. FAP-eligible patients under the External Screening Process are provided discounts for eligible services for retrospective dates and subsequent visits for six months; see 2019 VUMC Charity Guidelines for additional information. The model’s rule set is designed to assess each patient to the same standards. The External Screening Process enables VUMC to assess whether a patient is characteristic of other patients who have historically qualified for financial assistance under the Application Process. Uninsured patients may be screened through the External Screening Process at any time to determine financial assistance eligibility. Underinsured patients will be screened through the External Screening Process after 120-days without payment or initiating a financial assistance application to determine financial assistance eligibility. VUMC provides patient name, address, social security number (SSN), date of birth (DOB), and phone number to the vendor as part of this determination process.

The Alternate Charity Process is for instances when a patient is NOT Medicaid eligible but appears eligible for charity care discounts, but there is no financial assistance form on file because the patient cannot provide the routine documentation required to approve a traditional financial assistance application.  FAP-eligibility may be determined on the basis of individual life circumstances, as provided by the patient, that may include but  are not limited to :

1. State-funded prescription programs;

2. Homeless or received care from a homeless clinic;

3. Participation in Women, Infants and Children programs (WIC);

4. Food stamp eligibility;

5. Subsidized school lunch program eligibility;

6. Eligibility for other state or local assistance programs that are unfunded (e.g., TennCare spend-down);

7. Low income/subsidized housing is provided as a valid address; and

8. Patient is deceased with no known estate.

FAP-eligible patients under the Alternate Charity Process are automatically qualified for a 100% discount without further investigation. 

The Alternate Charity Process may be used at any point prior to or after the 120-day period. Discounts will be applied to medically necessary patient accounts, professional and technical. Subsequent eligible services for six months following the discount approval date will also receive the same discount.  After six months, the patient must be reprocessed for financial assistance eligibility.

The qualification for Financial Assistance will be based on only on the combination of family size and the annual adjusted gross income of the patient (or patient’s household if filing jointly) for the most recent year available based on either the most recently filed tax returns, income data received in the External Screening Process, or from the most current documents noted below.  Calculation of annual adjusted gross income and family size are based on information taken from recent family tax returns and must be provided to verify income and family size.

If an applicant does not have current tax returns or if no information is received in the External Screening Process, VUMC may accept W9, 1099, food stamp adjudication letters, disability award letters, other official government documentation of income, three months of pay stubs, or bank statements for one year.

To meet the income requirements, the adjusted gross income of the patient (or the patient’s household) for the current or prior year may not exceed 2.5 times the Federal Poverty Guideline (FPG).  For patients with adjusted gross income of less than or equal to 2 times the FPG, a 100% Financial Assistance Discount will be applied to Estimated Patient Liability.  For patients with adjusted gross income above 2 times but less than or equal to 2.5 times FPG for the most recent year, a sliding scale discount will be applied to Estimated Patient Liability in percentage increments based upon income and family size. 

If the adjusted gross income of the patient exceeds 2.5 times FPG, the patient may still be eligible for Catastrophic Financial Assistance if the patient’s un-reimbursed medical expenses at VUMC during a one-year period exceed 100% of the responsible party’s annual household income as described in the Patient Discounts Policy

Please refer to the Charity Guidelines page for current discount amounts provided relative to the most current year available Federal Poverty Guidelines.

Patients should be closely monitored for the existence of charity status as soon as its practical.  As soon as the need is observed the patient should be informed of the financial assistance program and encouraged to complete the application.  Patients should be encouraged to complete the application within one hundred twenty (120) days from the date VUMC sends the first “post discharge” billing statement.  Extraordinary Collection Actions will not be taken by VUMC during this window. If the patient begins the Application or External Screening Process during the 120-day period but cannot complete this Application Process, the patient will be provided at least another 120-days after the date of application to complete the Application Process before Extraordinary Collection Actions are taken by VUMC. The Alternate Charity Process may be used at any point prior to or after the 120-day period.

Discounts will be applied to medically necessary patient accounts, professional and technical. Subsequent eligible services for six months following the discount approval date will also receive the same discount.  After six months, the patient must be reprocessed for financial assistance eligibility.

III. Basis for Calculating Patient Charges and Amounts Generally Billed

Patients who meet the VUMC eligibility criteria defined in this policy will not be charged more for emergency or other medically necessary care than the Amounts Generally Billed (AGB) to individuals who have insurance covering such care. However, all uninsured patients will be provided an uninsured Discount prior to the first billing statement. This Uninsured Discount is given without consideration of patient financial status. This Uninsured Discount may be ultimately classified as a Financial Assistance Discount if the patient meets the income-based criteria identified through either the External Screening Process or traditional Application Process. In accordance with the Tennessee regulations, uninsured patients are not to pay for services in an amount that exceeds one hundred seventy-five percent (175%) of the cost for the services provided (calculated using the cost to charge ratio in the most recent joint annual report). VUMC has chosen to use the discount calculated from the IRS 501(r) regulatory guidance pertaining to AGB as the discount to be applied to uninsured and underinsured patients who have received eligible healthcare services.

In accordance with Internal Revenue Code Section 501(r) requirements, VUMC utilizes the “Look Back Method” to determine the AGB percentage based on claims from the prior 12-month period ending Dec 31 of each year. The AGB percentage is determined by using the calculated expected reimbursement from all claims allowed by Medicare fee-for-service and all private health insurers and dividing that total reimbursement by total charges for the same claims.  The resulting percentage represents the AGB for Medicare and private insurers. VUMC includes hospital and physician claims which occur in both the hospital and hospital-based clinic settings in the AGB calculation. VUMC removes from the calculation all claims 100% denied by the applicable insurers and claims which are in a credit balance status.  The AGB percentage is then updated as of April 30th of each fiscal year based on the analysis described above. 

Therefore, patients who are eligible for an Uninsured Discount are not expected to pay more than the AGB.  

IV. Method for Applying for Financial Assistance

Patients may obtain Financial Assistance applications via the following website: www.vanderbilthealth.com/FinancialAssistance; by calling customer service at (888) 274-7849, by contacting VUMC inpatient registration locations, or by visiting the VUMC Financial Business Office at 719 Thompson Lane in Nashville, TN.

Inpatient locations:
VUMC Admitting 1107
1211 Medical Center Drive
Nashville, TN 37232
615-322-5000

MCJCHV Business Center, 1st floor
2200 Children’s Way
Nashville, TN 37232
615-936-1000

Patients should mail complete financial assistance to VUMC Customer Service at 719 Thompson Lane Suite 30330, Nashville, TN 37204 for program eligibility determination. Determinations are normally completed within thirty (30) business days after receipt.

The Financial Assistance Policy applies to VUMC-employed providers of emergency and other medically necessary care in its facilities. All providers of emergency and medically necessary care in VUMC hospital facilities are VUMC-employed providers.

V. Actions that may be Taken in the Event of Nonpayment

Patients will receive monthly bill(s) for amounts greater than $5 that VUMC determines are their responsibility, after any insurance plan payments have been applied.

Patients will receive billing statements or phone calls during a one hundred twenty (120) day period reminding them of their bill(s). During this period, patients will be expected to pay their bill(s) in full, establish a payment plan, or apply for Financial Assistance.

See the Patient Collections Policy for more information.

VI. Use of Extraordinary Collection Actions (ECAs)

VUMC strives to assist all patients prior to enlisting the assistance of a collection agency. Patients will have one hundred twenty (120) days from the date the first billing statement is generated to complete the Financial Assistance Application or External Screening Process before any Extraordinary Collections Actions are considered or taken. See the Patient Collections Policy for a description of the reasonable efforts VUMC and its collection agencies take to determine an individual’s FAP eligibility before engaging in ECAs against that individual.

In select cases, VUMC may choose to engage an attorney in a collection action. This step would occur after Patient Financial Services Leadership first reviews each case to determine if all reasonable efforts have been made to assist patient access to VUMC Financial Assistance before taking ECA. Such documentation will be presented to both the Associate Vice President for Patient Financial Services and the Senior Vice President for Revenue Cycle for review and approval prior to an ECA.

VII. Eligibility Information Obtained from Other Source

Patients that are unresponsive to inquiries by VUMC may be screened through an External Screening Process to determine estimated income amounts for Financial Assistance eligibility prior to placement with a collection agency.

As noted above, if a patient’s account has an outstanding balance that exceeds $1,000, and no other party is responsible for the bill, VUMC will submit the patient’s information through an External Screening Process to determine estimated income amounts, before sending it to collections, and will automatically apply the appropriate discount if the patient qualifies. VUMC provides patient name, address, SSN, DOB, and phone number to the vendor as part of this determination process. 

VIII. Other Information

Uninsured patients will be provided an Uninsured Discount which is equal to the AGB Discount as outlined in the Patient Discounts Policy.  This Uninsured Discount is given regardless of financial status. It may be ultimately reclassified as a Financial Assistance Discount if the patient subsequently meets the qualifications described in this policy. 

If a patient submits a complete Financial Assistance application and is determined to be eligible, VUMC will refund any amounts the patient has paid for care that exceed the amount they are determined to be personally responsible for paying.

It is routine and customary for VUMC patients to receive scripts for pharmaceuticals to facilitate their care post discharge as a component of their on-going care plan.  The nature of the discharge process is transitional and designed to effectively and efficiently arrange for the patient’s care in the next venue.  Discharge Medications to be obtained at a Retail Pharmacy are a key component of the patient care transition.  However, Retail Pharmacies follow a point of sale model requiring settlement of obligations prior to dispensing of the drugs which is a potential barrier to patient care transitions.  Thus, VUMC allows professionals involved in a patient’s clinical care to deem a patient as eligible for financial assistance to receive Discharge Medications without expectation of payment.  Discharge Medications can be provided free of charge to patients for a specific period of time at the request of Social Services, Physicians, Nurses, Pharmacist, Care Managers or their licensed clinicians. 

VUMC community outreach efforts to care for the uninsured in the greater Nashville area include both clinics operated directly by VUMC such as the Shade Tree Clinic and Homeless Street Clinic, as well as collaborative efforts with other independent charities including the Siloam Clinic.  VUMC’s clinical commitment to these patients can range from providing patients free prescription drugs to accepting referrals for higher acuity clinical services without the expectation of payment. 

VUMC Patient Financial Services staff makes the final determination about financial assistance.  An appeals process is available to individuals and requires completion of the appeals application.  

For patients receiving eligible healthcare services who qualify or qualified for Medicaid and whose States’ Medicaid Program has been deemed bankrupt, VUMC will immediately write off 100% of unpaid balances to Financial Assistance.  The patient will not be required to complete a Financial Assistance application since they were deemed Medicaid qualified in the corresponding State. 

Any exceptions to this policy must be approved by the VUMC Chief Executive Office and / or the VUMC Chief Financial Officer. Financial Assistance is calculated according to the Federal Poverty Guidelines.

If you need assistance, please visit the Contact Information page.

EXHIBITS 

2019 Vanderbilt University Medical Center Charity Guidelines

Catastrophic Care Guidelines

Amounts Generally Billed (AGB)

Rapid Charity Care Financial Assistance Application

Financial Assistance Application

Financial Assistance Appeal Application

REFERENCES:

Patient Discounts Policy

Patient Collections Policy