PURPOSE

To ensure that the sliding fee scale program is patient-centered, improves access to care, and assures that no patient will be denied health care services due to an inability to pay..

STATEMENT OF POLICY

All patients seeking emergent health care services at St. Vincent Health are assured that they will be served regardless of ability to pay. No one is refused service because of lack of financial means to pay.

A Sliding Fee Discount Program will be provided to eligible persons based on their household and income as defined by the Federal Poverty Guidelines Sliding Fee Scale Chart. Sliding fees are specific to all individuals and families with annual incomes at or below 200 percent of the federal poverty line.

Fee Discount Program will be offered to all who are unable to pay for their services. St. Vincent Health will base program eligibility on a person’s ability to pay and will not discriminate on the basis of an individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity. The Federal Poverty Guidelines are used in creating and annually updating the sliding fee schedule (SFS) to determine eligibility.

PROCEDURE

1. Administration: The Sliding Fee Discount Program procedure will be administered through the the business office with assistance from anicillary areas or their designee. Information about the Sliding Fee Discount Program policy and procedure will be provided and assistance offered after completion of the application. Dignity and confidentiality will be respected for all who seek and/or are provided charitable services.
2. Alternative payment sources: All alternative payment resources must be exhausted, including all third-party payment from insurance(s), Federal and State programs.
3. Application: The patient/responsible party must complete the Sliding Fee Discount Program application in its entirety. By signing the Sliding Fee Discount Program application, persons authorized from St. Vincent will access all information and confirm income as disclosed on the application form. Providing false information on a Sliding Fee Discount Program application will result in all Sliding Fee Discount Program discounts being revoked and the full balance of the account(s) restored and payable immediately.
4. Initial application: If an application is unable to be processed due to the need for additional information, the applicant has two weeks from the date of notification to supply the necessary information without having the date on their application adjusted. If a patient does not provide the requested information within the two-week time period, their application will be re-dated to the date on which they supply the requested information. Any accounts turned over for collection as a result of the patient’s delay in providing information will not be considered for the Sliding Fee Discount Program.
5. Renewal applications: A patient who receives discounted services under this policy is required to submit an updated application every 12 months or if their financial situation changes. Failure to meet the annual financial information requirement may result in the patient no longer being eligible for the Sliding Fee Discount Program. If a patient is delinquent in meeting the updated annual application requirement, St. Vincent will mail the patient a notice they are being terminated from the Sliding Fee Discount Program unless they submit the required financial information within the time frame (10 business days) noted in the letter. If a patient does not submit the renewal information, they are no longer eligible for the discounted services per the date in the notice letter.
6. Discounts: Discounts will be based on income and family size only which could include the HDC program or which ever comes first.
7. Income includes: Earnings, 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 household, and other miscellaneous sources. Noncash benefits (such as food stamps and housing subsidies) do not count.
8. Requirements: Applicants must provide the following: prior year W-2, two most recent bank statements, and two most recent pay stubs. Self-employed individuals will be required to submit detail of the most recent three months of income and expenses for the business. Adequate information must be made available to determine eligibility for the program. Self-declaration of income may only be used in special circumstances. Specific examples include participants who are homeless. Patients who are unable to provide written verification must provide a signed statement of income, and why they are unable to provide independent verification. This statement will be reviewed and final determination as to the sliding fee percentage will be made. Self-declared patients will be responsible for 100% of their charges until management determines the appropriate category.
9. Updates: The sliding fee schedule will be updated during the first quarter of every calendar year with the latest federal poverty guidelines (http://aspe.hhs.gov/poverty) 
10. Notice: The Sliding Fee Discount Program determination will be provided to the applicant(s) in writing, and will include the percentage of Sliding Fee Discount Program write off, or, if applicable, the reason for denial. If the application is approved for less than a 100% discount or denied, the patient and/or responsible party must immediately establish payment arrangements with [Name of Practice].

a. The applicant has the option to reapply after the 12 months have expired or any time there has been a significant change in family income. When the applicant reapplies, the look back period will be the lesser of six months or the expiration of their last Sliding Fee Discount Program application. 

1. Refusal to pay: If a patient verbally expresses an unwillingness to pay or vacates the premises without paying for services, the patient will be contacted in writing regarding their payment obligations. If the patient is not on the sliding fee schedule, a copy of the Sliding Fee Discount Program application will be sent with the notice.

a. If the patient does not make effort to pay or fails to respond within 60 days, this constitutes refusal to pay. At this point in time, [Name of Practice] can explore options not limited to, but including offering the patient a payment plan, waiving of charges, or referring for patient collections efforts.

Storage of information:

Information related to Sliding Fee Discount Program decisions will be maintained and preserved in a shared confidential file located in business office, in an effort to preserve the dignity of those receiving free or discounted care.

FAP Covered Providers:

Below is a complete list of all the providers who deliver emergency or medically necessary care at St. Vincent Health. All of the listed providers are covered by this Financial Assistance policy.

·         Jonathan Tashkin, MD

·         Jeffrey Beckman, MD

·         Heather Naiman-Crysel, MD

·         James Brewer, MD

·         Gilbert Pineda, MD

·         David Wiebe, PA

·         Christopher Holmes, MD

·         Neal O’Connor, MD

·         Andrew Walshak, MD

·         William Jared Scott, MD

·         Stephen Nikaido, PA

·         John Timmins, PA

·         Richard Tsambikos, DO

·         Lisa Zwerdlinger, MD

POLICY VIOLATION

Any SVH employee who fails to abide by this policy may be subject to disciplinary action, up to and including termination.