I. Financial Assistance Application Guideline(s):

1. Financial assistance adjustments are available for medically necessary services. Non-essential services are not considered for financial assistance, for example: cosmetic service, maternity services, bariatric services, plastic services, balances due as a result of contracted services or services deemed non-emergent by review of a Medical Director and recommendations made to Senior Finance staff.  

2. Applicants need to be aware that falsifying information on the application will be grounds for denying or revoking financial assistance. Falsifying an application includes, but is not limited to, failure to disclose assets, as well as transferring assets to avoid reporting them.

3. Applicants are required to complete and sign the financial assistance application provided by St.Vincent’s Health System. When a signed application is not available, completion of the application via the phone will be witnessed by two STVHS associates. The application focuses on identifying the size of the family unit and financial information sufficient to determine if the applicant qualifies for financial assistance. The financial information required includes, but not limited to, monthly income and expenses, as well as assets and liabilities. This application will be valid for a period of 6 months from the date received and accepted as complete by STVHS.

4. The applicant will be asked to provide proof of gross household income such as:
   Last 3 pay stubs
   Social Security Check copy
   Income Tax Return         
   W-2 Form         
   Other records documenting income
   Food Stamp Letter
   SSI Disability Letter - Letter from Social Security office
   DIR Form

5. Applicants identifying themselves as homeless will be offered charity care based on lack of third party coverage and no available assets.  The financial counselor will attempt to contact the shelter where the patient is resident if possible. A credit check will be run to confirm the patient’s residence and financial situation.
   
   
6.  Applicants are invited to submit any additional documentation they feel may be useful in the evaluation and determination process including information detailing permanent or severe illness, extenuating circumstances, and expenses such as prescription drugs, child care, and alimony/child support.

7. If applicable the patient’s insurance is filed and payment is received from the insurance company before determining any financial assistance adjustment. Failure of an applicant to cooperate with claims filing, or collecting from a potential third party resource, will be grounds for denying financial assistance.

8. Hardship charity may be awarded on an individual basis for extenuating circumstances as determined by the Financial Counselor and approved by the appropriate level of management described below. The award of hardship charity will be approved per incident and reviewed with each subsequent visit. Supporting documentation for hardship charity requires an application, a supporting document of some type indicating a need for hardship charity such as a letter from a homeless shelter, a letter from someone providing sole support etc, and a credit check.The VP of Revenue Cycle may at his/her discretion approve a hardship charity application in the absence of the inability to obtain all the requested documents.

9. Applicants 25 years of age and under will be subject to submission of the financial information of the patient’s parents or guardian.

10. Financial Assistance will only be granted for patients with accounts currently at a facility or scheduled future visits. Charity will not be granted unconditionally for a period of time.

11. Approval for charity care at one STVHS facility will be valid at all STVH facilities for the approval period. 

12. Approval for charity care may be considered at the guarantor level. When the patient is not the guarantor, STVHS will require additional documentation showing that the patient is receiving most of their support from the guarantor. An example would be a dependent on a parent’s tax return or the same address on the patient’s driver’s license as the guarantor.

II. Financial Assistance Procedures:

1. When hospital personnel identify patients for whom no financial means appear available, these patients are referred to the Financial Counselor/Representative. An appointment with the patient is made if the Counselor is not immediately available.

2. The Financial Counselor/Representative counsels with self-pay patients to determine the level of financial need and to determine payment arrangements prior to services if possible. If the patient’s situation appears to meet the financial assistance guidelines, an application for financial assistance is initiated.

3. The Financial Counselor/Representative reviews self-pay patients to identify possible financial assistance candidates. A Financial Assistance Application is initiated where applicable.

4. Every attempt will be made to assist the uninsured patient in becoming covered under any available assistance programs, state, local, federal or community based, etc.

5. When a financial assistance application is initiated, the Financial Counselor/Representative advises the applicant of the supporting documentation that is required before the financial assistance request will be considered.

6. The Financial Counselor/Representative follows up on incomplete financial assistance applications. If all supporting documentation is not submitted within 30 days of the application, the request for financial assistance is denied and the account continues through the self-pay cycle

7. When all data is received, the Financial Counselor/Representative reviews the application, completes the financial assistance forms, and indicates the recommendation for approval or denial on the application. The application is given to the appropriate individuals based on the account balance and amount of financial assistance adjustment requested.

8.  Approval authority for financial assistance and discounts for the uninsured and underinsured is based on the following criteria:
   1. Manager of Patient Access may approve adjustments up to $5,000.
   2. Revenue Cycle Director may approve adjustments up to $ 100,000.
   3. Vice President of Revenue Cycle and/or Vice President of Finance may approve adjustments greater than $100,000.  

9. Since the necessary signatures are completed and approval or denial is confirmed, the Financial Counselor sends the patient a letter informing them of the decision. The approval is for a period of 6 months before the discharge date or for scheduled future visits. Charity will not be granted unconditionally for a period of time in the future.

10. The Financial Counselor/Representative records the approval or denial in the computer system. In the case of a denial, the Financial Counselor indicates the reason for the denial. The Financial Counselor will also document in STAR when the letter was mailed to the patient.

11. If the application is approved, the patient should agree to payment arrangements on the remaining balance of their account with the Financial Counselor/Representative, and/or appropriate collection agency.

12. All documents pertaining to the Charity Application will be scanned to the SOVERA document imaging system. These documents will be scanned to the “charity” tab and viewable by individuals with designated security access. The documents will be maintained at the MPI rather than account level for a patient.

13. Once approvals have been obtained the patient information will be sent to the business office so the adjustment can be processed. The designated business office employee will also confirm that the letter to the patient has been sent before processing the adjustment.

III. Financial Assistance Standards:
To be considered for a financial assistance allowance, the following criteria must be met:

1. The Federal Poverty Level (FPL) as published annually in the Federal register will be the basis for guidelines used to qualify applicants. Based on gross income and family size, applicants will be eligible for allowance as follows:
   100%- 200%  FPL Base = 100% write off
   201% - 225% FPL Base = 80% write off
   226% - 250% FPL Base = 70% write off
   251% - 275% FPL Base = 60% write off
   276% - 300% FPL Base = 50% write off

2. Medical Indigence will be considered for applicants exceeding FPL guidelines and is defined as follows:
   1.  When the total outstanding medical debt exceeds the gross household income for the past year, the guarantor will be eligible for financial assistance. The max payment will not exceed 15% of the individual’s annual income as documented.

3. The Vice President of Revenue Cycle is responsible for monitoring the Federal Poverty Levels, and for updating and publishing the Income Criteria Table on which this policy is based. The updated Income Criteria Table will become effective automatically on the first of the month following publication.


4. The Vice President of Mission Services is empowered to authorize financial assistance care in special circumstances where as a judgment call on privileged and confidential information, it is imperative for the patient to receive immediate care. This authority extends only to those services necessary to manage the crises and stabilize the patient. It is also limited to those situations where the patient is refusing necessary care on the grounds that he/she cannot afford it. For clarity in communication, we shall call this privilege the “Mission Privilege.”

5. Granting charity care or financial assistance is at the sole discretion of Saint Vincent’s Health System.

IV. Discount for Uninsured Patients with the Ability to Pay

Uninsured patients with the ability to pay will be provided a discount based on an individual hospital schedule determined as of July 1st each year.  Patient Financial Services management will communicate the results at each facility.

Patient Right of Appeal
The patient has the right to a fair, efficient and timely process for appealing decisions regarding the amount of financial assistance provided by St Vincent’s Health System.  The patient has the right to appeal if their application is denied or if they feel the amount of financial assistance provided is incorrect.

If the patient wishes to file an appeal they must make the request in writing and provide the reason for the appeal within thirty (30) days from the time assistance is awarded. The appeal must include the patient’s full name, address, date of birth, social security number and dates of services rendered at St Vincent’s Health Systems. 

The written appeal must be sent to: St Vincent’s Health Systems PFS
                                                         Attn: Director-Patient Financial Services
                                                         50 Medical Park East Drive
                                                         Birmingham, AL 35235

Director of the Central Business Office will forward the request for appeal to the V.P. of Finance and the facility Chief Operating Office for review. Based on their determination the patient will be contacted and explained the decision.