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Sansum Clinic Charity Care

Sansum Clinic strives to provide quality patient care and high standards for the communities we serve.  This policy outlines Sansum’s commitment to our mission and vision by helping to meet the needs of the low income, uninsured, and underinsured patients in our community.  This policy is not intended to waive or alter any contractual provisions or rates negotiated by and between Sansum and a third party payer, nor is the policy intended to provide discounts to a non-contracted third party payer or other entities that are legally responsible to make payment on behalf of a beneficiary, covered person, or insured.

DEFINITIONS

Bad Debt - A bad debt results from services rendered to a patient who is determined by the clinic, following a reasonable collection effort, to be able but unwilling to pay all or part of the bill.

Charity Care Patient -  A Charity Care Patient is a financially qualified self-pay patient, or a low income patient with high medical cost.

Clinical Override -  The review process wherein the treating physician determines that the services requested are medically necessary and cannot be deferred.  The clinical override is completed by the treating physician and must receive approval by the Dean of Clinical Affairs or Designee, prior to treatment.

Emergent Medical Condition Service - A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

  • Placing the patient's health in serious jeopardy
  • Serious impairment to bodily functions
  • Serious dysfunctions of any bodily organ or part
Federal Poverty Level (FPL) - Poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services, published at: http://aspe.hhs.gov/poverty

Final Review Committee – Under this policy, the Chief Medical Officer (“CMO”) or the Medical Director, the Chief Operation Officer (“COO”), the Chief Financial officer (“CFO”), and the Compliance Officer (“CO”) are responsible for reviewing and approving all waivers of copayments, deductibles and charges. The advice of Counsel and approval by the Board, as necessary, may be obtained 

Financially Qualified - A Financially Qualified patient is defined as follows:
Uninsured patient with Family income at or below 400% of the FPL; or

 

  • Insured patient with High Medical Costs and a Family income at or below 400% of the FPL; or
  • Insured patient with non-covered charges and a Family income at or below 400% of the FPL; or
  • A patient, whether uninsured or insured, who has High Medical Costs.

High Medical Cost Patient - A Financially Qualified High Medical Cost patient is defined as follows:

  • Not Self-Pay (has third party coverage);
  • Family income at or below 400% of the Federal Poverty Level (FPL);
  • Out-of-pocket medical expenses in prior twelve (12) months (whether incurred in or out of any hospital) exceeds 10% of family income to include those whose treatment plan has been in the last 12 months, or going forward will likely be, costly due to amount and frequency of visits/bills.
Medically Necessary Service – A medically necessary  service or treatment is one that is absolutely necessary to treat or diagnose a patient and cold adversely affect the patient's condition, illness or injury if it were omitted, and is not considered an elective or cosmetic surgery or treatment.

Liquid Assets – To include cash, checking accounts, savings accounts, and money market accounts that are nonretirement brokerage accounts 

Patient’s Family - For patients 18 years of age and older, patient's family is defined as their spouse, domestic partner, dependent children under 21 years of age, whether living at home or not, and patient's parent(s) or other adult who claims the patient as a dependent for tax filing purposes.  For persons under 18 years of age, patient's family includes a parent, caretaker relatives and other children under 21 years of age of the parent or caretaker relative.

Reasonable Payment Plan – Monthly payments on balances $1000-$3000 not to exceed six months. Over $3000 not to exceed (12) twelve months.

Self-Pay Patient – A financially eligible Self-Pay patient is defined as follows:

  • No third party coverage;
  • No Medi-Cal/Medicaid coverage, or patients who qualify but who do not receive coverage for all services or for the entire stay;
    • This includes charges for non-covered services, denied days or denied stays. Treatment Authorization Requests (TAR) denials and any lack of payment for non-covered services provided to Medi-Cal patients are also included. In addition, Medicare patients who have Medi-Cal coverage of their co-insurance and/or deductibles, for which Medi-Cal does not make payment and Medicare does not ultimately provide bad debt reimbursement are also included.
  • No compensable injury for purposes of government programs, workers' compensation, automobile insurance, other insurance, or third party liability as determined and documented by Sansum Clinic;
  • Family income is at or below 400 % of the Federal Poverty Level (FPL).

POLICY

This policy is intended to comply with Section 501(r) of the Internal Revenue Code (IRC) as well as California Health & Safety Code section 127400 et seq. (AB 774), and Office of Inspector General, Department of Health and Human Services ("OIG") guidance regarding financial assistance to uninsured and underinsured patients.  Additionally, this policy provides guidelines for identifying and handling patients who may qualify for financial assistance.  This policy also establishes the financial screening criteria to determine which patients qualify for Charity Care.  The financial screening criteria provided for in this policy are based primarily on the Federal Poverty Level (FPL) guidelines updated periodically in the Federal Register by the United States Department of Health and Human Services. This policy will cover all services rendered within Sansum Clinic, The Ridley-Tree Cancer Center, and Foothill Surgery Center.

A. It is the policy of Sansum Clinic to provide assistance to Financially Qualified Patients who require medically necessary services, are uninsured, ineligible for third party assistance or have low income with high medical costs, and reside in Santa Barbara County, not to exclude homeless or transient populations. Special services for Ventura County patients will be considered on an adhoc basis.

B. Sansum Clinic is committed to providing services to all individuals based solely on the individual's medical need.

C. Patients with demonstrated financial need may be eligible if they satisfy the definition of a Charity Care patient or High Medical Cost patient.

D. Undocumented patients or non-US citizens residing in California in an undocumented status and demonstrate financial need are eligible for Charity Care discounts. 

E. Requests for Charity Care may be made at any point before, during, or for a minimum of 120 days from the first billing statement after the provision of care. 

F. The approved Charity Care level may be effective for a period of up to three months.   Financially Qualified Patients will require periodic screening for changes in eligibility.

G. This policy permits non-routine waiver of a patient's out-of-pocket medical costs based on an individual determination of financial need in accordance with the criteria set forth below.

H. This policy excludes routine waiver of deductibles, co-payments, and/or co-insurance imposed by insurance companies for patients whose family income is greater than 400% of the federal poverty level.

I. This policy excludes services which are not medically necessary or cosmetic.

J. In rare situations where a physician considers an excluded service to be medically necessary, such services may be eligible for a Charity Care discount upon review and approval by the Financial Review Committee who advises the Vice President, Patient Business Services.

K. This policy will not apply if the patient/responsible party provides false information about financial eligibility or if the patient/responsible party fails to make every reasonable effort to apply for and receive government sponsored insurance benefits for which they may be eligible.

L. This policy and the financial screening criteria will be consistently applied to all cases throughout Sansum Clinic. If application of this policy conflicts with payer contracting or coverage requirements, consult with Sansum Clinic counsel.

M. Excluded services include but are not limited to:

1. Services considered non-covered or not medically necessary;

2. Patients who have insurance but choose not to utilize coverage, even due to privacy reasons;

3. Elective cosmetic surgery procedures;

4. Other elective procedures (e.g., include but are not limited to infertility services,  sterilization, reversal of sterilization, circumcision, family planning certain eye surgeries, and routine vision exams); other elective procedures deemed not medically necessary based on coding guidelines.

5. Medical equipment. (e.g., eyeglasses, contact lenses, hearing aids).

PROCEDURE

I. Communication of Charity Care and Discount Policies

A. The Charity Care Policy will be posted on Sansum Clinic’s website in languages as determined by Sansum’s geographical area.  Sansum Clinic’s Social Work Services and Financial Counseling departments shall publish policies and train staff regarding the availability of procedures related to patient financial assistance.

II. Eligibility Procedures

A. Patients without third party coverage will be screened by appropriate staff for potential eligibility for state and federal governmental programs as well as Charity Care funding at the time of service or as near to the time of service as possible.  If the patient does not indicate coverage by a third-party payer, or requests a discounted price or Charity Care, the patient should be provided with an application for the Medi-Cal program or coverage offered through the California Health Benefits Exchange, or other state or county-funded health coverage program.

B. Low income patients with third party coverage and high medical costs will be screened by appropriate staff to determine whether they qualify as a High Medical Cost patient.  Upon patient request for a Charity Care discount, the patient will be informed of the criteria to qualify as a High Medical Cost patient and the need to provide receipts if claiming services rendered at other providers in the past twelve months.  It is the patient's decision as to whether they believe that they may be eligible for charity and to apply.  However, Sansum must insure that all information pertaining to the Charity Care Policy was provided to the patient.

C. All potentially eligible patients must apply for assistance through State, County and other programs before Charity Care funds are considered.   If denied, Sansum must receive a copy of denial.  Failure to comply with the application process or provide required documents may be considered in the determination.  Willful failure by the patient to cooperate may result in Sansum’s inability to provide financial assistance.

D. The Financial Screening Form is used to determine a patient's ability to pay for services at Sansum Clinic and/or to determine a patient's possible eligibility for public assistance.

E. All uninsured patients will be offered an opportunity to complete a Financial Screening Form.  The form is available in English and in languages as determined by Sansum’s geographical area.

F. The Charity Care financial screening and means testing (Propensity to Pay screening) will be performed by appropriate staff.  It is the patient's responsibility to cooperate with the information gathering process.

G. Patient-specific information will be provided to the County and State in accordance with County and State guidelines for eligibility determinations.

H. In accordance to California Health and Safety Code 127405 (c) the charity care policy shall state clearly the eligibility criteria for charity care.  In determining eligibility under its charity care policy, a hospital may consider income and monetary assets of the patient.  For purposes of this determination, monetary assets shall not include retirement or deferred compensation plans qualified under the Internal Revenue Code,   1 or nonqualified deferred compensation plans.  Furthermore, the first ten thousand dollars ($10,000) of a patient's monetary assets shall not be counted in determining eligibility, nor shall 50 percent of a patient's monetary assets over the first ten thousand dollars ($10,000) be counted in determining eligibility.

III. Eligibility for 100% Charity Care
A. Patients without third party coverage and income at or below 250% of the FPL may be extended a 100% Charity Care discount on services rendered. 

B. Means testing consists of review of patient's income and screening using the Propensity to Pay portal.  Family income will be verified with either the most recent filed federal tax return or recent paycheck stubs, to include year to date income.  Additional information regarding liquid assets may be required based on review of the tax return.

C. The Financial Screening Form should be completed for all patients requesting a Charity Care discount.

D. Criteria and process to determine a patient's eligibility for a 100% charity care discount are as follows:

1.      Patient's family income is verified not to exceed 250% of FPL with the most recent filed Federal tax return or recent paycheck stubs.

E. High Medical Cost patients with third party coverage who are below 200% of the FPL with medical costs in excess of 10% of the patient's family annual income will be extended a 100% Charity Care discount on services rendered.

F. High Medical Cost patients will be evaluated every three months for eligibility determination, and their status will be valid for the current month or most current service month with a 120 day review for retroactive Charity Care.

G. The Financial Review Committee may instruct the Vice President of Patient Business Services, under unusual circumstances, to extend Charity Care funding to individuals who would not otherwise qualify for Charity Care under this policy. When such an award is made, the patient's account will be clearly documented with the unusual circumstances justifying the award of Charity Care.

IV. Eligibility for Partial Charity Care Discount for Patients with No Third Party Coverage (Self-Pay)
 
A. Patients with no third party coverage with family income between 251% and 400% of FPL are eligible for a partial Charity Care discount. 

B. Means testing consists of review of patient's income and screening using the Propensity to Pay portal.  Family income will be verified with either the most recent filed federal tax return or recent paycheck stubs.  Additional information regarding liquid assets may be required based on review of the tax return.

C. The Financial Screening Form should be completed for all patients requesting a Charity Care discount.

D. Criteria and process to determine a patient's eligibility for a Partial Charity Care discount are as follows:

1. Patient's family income is verified to be between 201% and 400% of FPL with the most recent filed Federal tax return or recent paycheck stubs. 

2. Sansum Clinic will use a sliding scale approach to determine the Charity Care discount depending on Patient/Family Income. This may result in a different Charity Care discount for the same service depending on income level.

E. Patients can be offered an extended payment plan. The terms of the payment plan can be established by the Customer Service team and the patient. Sansum shall use the formula described in the definition of "Reasonable Payment Plan," in section Ill above.

V. Eligibility for Partial Charity Care Discount for High Medical Cost Patients with Third Party Coverage

A. High Medical Cost patients with third party coverage whose family incomes are between 251% and 400% of FPL with high medical costs are eligible for a partial Charity Care discount.  High medical costs are 10% of annual family income paid for medical costs in the last twelve months.

B. Patient is required to provide proof of payment of medical costs.  Proof of payment may be verified.

C. The Financial Screening Form should be completed for all patients requesting a Charity Care discount.

D. Criteria and process to determine a patient's eligibility for Partial Charity Care Discount for High Medical Costs are as follows: Patient’s family income is verified to be between 251% and 400% of FPL with the most recent filed Federal tax return or recent paycheck stubs.

E. High Medical Cost patients need to be evaluated every three months to accurately account for medical cost for the last twelve (12) months, and their status will be valid for the current month or most current service month with a 120 day review for retroactive Charity Care.

F. If a third-party payer has paid an amount equal to or more than the maximum governmental program payment, Sansum Clinic would consider the difference as a partial Charity Care discount, and write off the balance.

G. If payment received is less than the maximum governmental program payment, Sansum Clinic can collect from the patient the difference between the third-party payment and the acceptable governmental program payment.   However, this policy does not waive or alter any contractual provisions or rates negotiated by and between Sansum and a third party payer, and will not provide discounts to a non-contracted third party payer or other entities that are legally responsible to make payment on behalf of a beneficiary, covered person, or insured.

VI. Review Process

A. Responsibility:  Financial Review Committee to advise Revenue Cycle Leader and/or designee.

B. Requirements above will be reviewed and consistently applied throughout
Sansum Clinic in making a determination on each patient case.

C. Information collected in the Financial Screening form may be verified by Sansum Clinic. The patient's signature on the Financial Screening Form will certify that the information contained in the form is accurate and complete.

D. Any patient, or patient's legal representative, who requests a Charity Care discount under this policy shall make every reasonable effort to provide Sansum with documentation of income and all health benefits coverage.

E. Failure to provide information would result in denial of Charity Care discount.

F. Eligibility will be determined based on patient’s family income and liquid assets.

G. Requests for Charity Care may be made at any point before, during, or after the provision of care.

H. The approved Charity Care level may be effective for a period of up to 6 months.

I. Financially Qualified Patients will require periodic screening for changes in eligibility.

J. Patients who are homeless or expire and have no source of funding, responsible party, or estate may be eligible for Charity Care even if a financial assistance application has not been completed. All such cases must be approved by the Financial Review Committee who will advise Vice President of Patient Business Services or their designees.

K. Patients will be notified in writing of approval or reason for denial of Charity Care eligibility in languages as determined by Sansum’s geographical area pursuant to federal and state laws and regulations within 20 days of receiving a completed Financial Screening Form and all required documentation.

L. Specific payment liability for partial Charity Care discounts will require the episode of care or treatment plan to be determined and priced to enable accuracy of federal healthcare program reimbursement reporting. For patients with third party coverage with high medical costs, it may be necessary to wait until a payer has adjudicated the claim to determine patient financial liability.

VII. Presumptive Eligibility for Charity Care

A. Sansum recognizes that not all patients, or patients' guarantors, are able to complete the Financial Screening Form or provide required documentation.

B. For patients, or patients' guarantors, who are unable to provide required documentation but meet certain financial need criteria, Sansum may nevertheless grant a Charity Care discount. In particular, presumptive eligibility may be determined on the basis of individual life circumstances that may include:

1. State-funded prescription programs;

2. Homeless or one who 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., Medicaid spend-down);

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

8. Patient is deceased with no known estate.

C. For the purpose of assisting a patient that communicates a financial hardship, Sansum may utilize a third-party portal (Propensity to Pay) to review a patient's, or the patient's guarantors, information to assess financial need.

D. This review utilizes a healthcare industry-recognized, predictive model that is based on public record databases. The model incorporates public record data to calculate a socio-economic and financial capacity score. The model's rule set is designed to assess each patient to the same standards and is calibrated against historical Financial Assistance approvals for Sansum Clinic. The portal allows Sansum Clinic to assess whether a patient is characteristic of other patients who have historically qualified for financial assistance under the traditional application process.

E. Information from the predictive model may be used by Sansum to grant presumptive eligibility, or to satisfy the documentation requirements for patients or their guarantors, in cases where there is an absence of information provided directly by the patient, and after efforts to confirm coverage availability.

F. In the event a patient does not qualify under the presumptive rule set, the patient may still provide required information and be considered under the traditional financial assistance application process set forth above in Section V.

G. Patient accounts granted presumptive eligibility status will be adjusted accordingly. These accounts will be reclassified under the Charity Care Policy.  The discount provided will not be sent to collection and will not be included in Sansum Clinic’s bad debt expense.

VIII. Patient Billing and Collection Practices

A. Responsibility: Patient Business Services.

B. Patients who have not provided proof of coverage by a third party at or before care is provided will receive a statement of charges for services rendered.  Included in that statement will be a request to provide Sansum Clinic with health insurance or third party coverage information.  

C. Patient's Charity Care request can be communicated verbally or in writing and a Financial Screening Form will be given/mailed to patient/guarantor address.  Written correspondence to the patient shall also be in the languages as determined by Sansum’s geographical area pursuant to federal and state laws and regulations.

D. If a patient is attempting to qualify for eligibility under Sansum’s Charity Care policy, and is attempting in good faith to settle the outstanding bill, Sansum shall not send the unpaid bill to any collection agency or other assignee unless the entity has agreed to comply with this policy.

E. Patients are required to report to Sansum any change in their financial information promptly.

F. Bills that are not paid 120 days after the billing statement may be placed with a collection agency.  The patient or the patient's guarantor can apply for help with their bill up to 120 days from the first billing statement and/or at any time during the collection process.

IX. Appeals/Reporting Procedures

A. Responsibility: Financial Review Committee who is to advise Vice President, Patient Business Services.

B. In the event of a dispute or denial, a patient may seek review from the Financial Review Committee who will advise Vice President, Patient Business Services and CFO.  The charity care committee will review a second level appeal.

C. All clinical exceptions/appeals must be requested in writing utilizing the Charity/Clinical Override Request form and must be reviewed and approved by charity care committee. Tracking and monitoring of physician's requests for Charity and Clinical Override will be monitored for clinical and financial appropriateness.  Cases deemed inappropriate may be denied and will be brought to the attention of the Financial Review Committee, CFO, Medical Director and Clinical Director.

X. Responsibility

A. Questions about the implementation of this policy should be directed to the Vice President, Patient Business Services at 805-681-1821.

B. Questions about Financial Assistance eligibility should be directed to the Financial Counseling Manager or the Vice President, Patient Business Services at 805-681-1821.

Please see the Charity Care forms below:

Sansum Clinic
Attn: Charity Care Coordinator
PO BOX 62106

Santa Barbara, CA 93160

 

RE: P&P 3-019, Charity Care | Revision date: 09/10/2020