ccipowerinside.com a new era of healthcare: 501(r) final regulations june 19, 2015 laurie shoaf,...

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A New Era of Healthcare: 501(r) Final Regulations

June 19, 2015

Laurie Shoaf, CRCE

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OBJECTIVES

• Review components of the 501r Regulation

• Define core elements of a compliant financial assistance policy

• Outline options for computing amounts generally billed

• Identify the reasonable efforts required before initiating extraordinary collection actions

• Q&A


DISCLAIMER STATEMENT

Information herein is believed, but not guaranteed, to be reliable, accurate and complete. Any opinions expressed herein reflect a judgment made as of this date and are subject to change. Neither CCI, its managers and governors, is making any representations, warranties, or guarantees with respect to the information contained herein or any action taken or not taken in reliance thereon and, in no event, shall such parties be liable for any loss, injury or damage arising therefrom, including, but not limited to, consequential, punitive or other similar damage claims.

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IRC 501(R)

• Section 501(r) (3) – Community Health Needs Assessments

• Section 501(r) (4) – Financial Assistance and emergency medical care policies

• Section 501(r) (5) – Limitations on charges for low-income patients

• Section 501(r) (6) – Billing & collections for low-income patients

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IRC 501(R)

• An organization that has the provision of hospital care as its principal function or purpose constituting the basis for its exemption under section §501(c)(3)

• Licensed within 50 states and D.C.

• Dual status Government hospitals must comply with 501r – However, may voluntarily terminate 501(c)(3) status

Hospital facility defined as

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IRC 501(R)

• Multiple hospital facilities that share the same state license may share a single FAP

• Separate hospital facilities within the same building may have identical FAPs as long as the policy is accurate for all facilities and a joint policy clearly states that it is applicable to each facility

• Whether or not 501r requirements apply to hospital-owned physician practices or other entities depends on how the entities are classified for federal tax purposes. If the organization is a separate taxable corporation, 501r would not apply

Unique Situations

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IRC 501(R)

If a hospital facility outsources the operation of its emergency room to a third party and the care provided by that third party is not covered under the hospital facility’s FAP, the hospital facility may not be considered to operate an emergency room for purposes of the factors considered in Rev. Rul. 69–545 (1969–2 CB 117)

Emergency Room

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TIMEFRAME FOR COMPLIANCE

• By beginning of first tax year after December 29, 2015

• First impacted hospitals are calendar year entities that must be in compliance on January 1, 2016

• “Reasonable interpretation” is required until then

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FIRST AUDIENCE POLL QUESTION

Where is your hospital on evaluating compliance with 501r regulations?

– Haven’t started yet

– Just started

– Almost done

– Finished

– Unsure

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FINANCIAL ASSISTANCE POLICY

Written Policy

Adopted by authorized

body

Method for

applying

Other sources used to make

FAP determinatio

n

Policy relating to Emergency

Medical care

Eligibility Criteria

Basis for calculating amounts charged

Actions that may be

taken for non-

payment

List of providers delivering

emergency or medically

necessary care

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Written Policy


body

Method for

applying


FAP determinatio

n


Medical care


Actions that may be

taken for non-

payment



necessary care

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Written Policy


body

Method for

applying


FAP determinatio

n


Medical care



Actions that may be

taken for non-

payment



necessary care

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Written Policy


body

Method for

applying


FAP determination


Medical care



Actions that may be

taken for non-

payment



necessary care

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• At a minimum, all emergency and other medically necessary care

• Medically necessary care may be defined by using:– Medicaid definition

– Generally accepted standards of medicine

– As defined under state laws

Written FAP Must Apply to

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• Description of all financial assistance offered and eligibility criteria for each category

• Method for applying for financial assistance and documentation requirements– May grant assistance based on evidence other than

that described in FAP

– May obtain information orally from applicant rather than in writing

– Presumptive determinations allowed

Written FAP Must Include

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• Explain basis for calculating amounts charged to patients– IRS recognizes discounts might be offered outside of

FAP, such as an uninsured or prompt pay discount

– Those discounts do not have to comply with 501(r)

– They also do NOT count as “community benefit” on schedule H of the 990 or for evaluating a hospital’s tax exempt status


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• Presumptive eligibility requirements outlined in the Final regulations require a hospital facility to:– Describe information obtained from sources other than

individuals seeking assistance that the hospital uses, and

– Whether and under what circumstances it uses prior FAP-eligibility determinations, to presumptively determine that individuals are FAP eligible


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• Description of actions may take in the event of non-payment, only in the case where a hospital facility does not have a separate billing and collections policy

• An Emergency Medical Care Policy can be included in the same document as an FAP or an already existing document related to EMTALA


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• List of providers, other than the hospital, delivering emergency or other medically necessary care in the facility and to specify which providers are covered by the hospital FAP (and which are not)

• Adopt the FAP by an authorized body of the hospital organization

• Final regulations eliminate the requirement that the FAP list the measures taken to widely publicize the FAP


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1. Make the FAP, FAP application form, and a plain language summary widely available on the hospital Web site

2. Make paper copies of the FAP, the FAP application form, and a plain language summary available upon request and without charge, both for distribution in public locations in the hospital, at a minimum in the emergency room and admissions and by mail

Four Measures to Widely Publicize the FAP

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3. Inform and notify visitors to the hospital about the FAP– Includes notification about the FAP through a conspicuous

public display (or through other measures reasonably calculated to attract visitors’ attention)

– Final rule adds the requirement for hospitals to widely publicize their FAPs by providing FAP information to patients before discharge and with billing statements


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• Final regs require only that a hospital ‘‘offer’’ (rather than ‘‘provide’’) a plain language summary as part of the intake or discharge process

• A hospital will not have failed to widely publicize its FAP because:– An individual declines to take a plain language summary

that the hospital facility offered on intake or before discharge or

– Indicates that he or she would prefer to receive or access a plain language summary electronically rather than receive a paper copy


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• Final regs no longer require a full plain language summary with all billing statements

• Requires only that a hospital’s billing statement include:– Conspicuous written notice that notifies and informs

about the availability of financial assistance under the FAP

– Telephone number of the office or department that can provide information about the FAP and FAP application process and

– Web site address (or URL) where the copies of the FAP documents may be obtained


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4. Inform and notify members of the community served by the hospital about the FAP in a manner reasonably calculated to reach those members of the community who are most likely to require financial assistance


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PLAIN LANGUAGE SUMMARY

• Brief description of eligibility requirements and assistance offered

• Direct website address and physical location where copies of the FAP and FAP application are available

• Brief summary of how to apply for assistance under the FAP

• How to obtain free copy by mail

• Contact information of either the hospital office or department that can provide assistance with the FAP application process

• Availability of translations

• Statement that no FAP-eligible patient will be charged more than AGB

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TRANSLATION OF FAP DOCUMENTS

• Documents must be made available in:– English and

– In the primary language of populations with limited English proficiency (LEP) that constitute more than 5 percent of residents, or 1000, whichever is less, of the population served

• May use any reasonable method to determine limited proficiency populations

Translation Threshold Changed in Final Rule

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• Prepare FAP documents

• Adopt the FAP by an authorized body of the hospital organization

• Translate documents when language minority constitutes more than 5% of the patient population or 1000 individuals

• Identify actions to widely publicize the FAP

Summary of High Level Tasks

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LIMITATION ON CHARGES

• Hospital facility must limit the amounts charged for any emergency or other medically necessary care it provides to a FAP-eligible individual to not more than AGB

• Also requires a hospital facility to limit the amounts charged to FAP-eligible individuals for all other medical care covered under the FAP to less than the gross charges for that care

Amounts Generally Billed

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AGB Methods

Prospective Method

Look-back Method

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• Final regs do not allow for a system wide AGB– If a health system bills Medicare under one provider

number it is allowed to calculate one AGB

– Different facilities operated by same organization may use different methods

• May change the method used to determine AGB at any time

• FAP should be updated to reflect changes prior to implementing

Amounts Generally Billed

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• Options include:– Medicare-fee-for-service

– Medicare-fee-for-service and all private insurers who pay claims to hospital

– Medicaid, either alone or in combination with insurers listed above

Health Insurers Used in Look-back Method

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• Begin using by 120th day after end of 12-month period

• LB method uses only claims that have been resolved

• May choose to use claims allowed for all medical care rather than just emergency and other medically necessary care

Look-back Method

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• Estimate the amount that would be paid by Medicare and a Medicare beneficiary using the same billing and coding process the hospital uses for Medicare beneficiaries

• The final rule allows the use of Medicaid, either alone or in combination with Medicare

Prospective Method

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• Hospital will remain compliant if more than AGB is charged in these conditions:– Individual has not been determined as FAP eligible

– Complete FAP application has not been submitted

– If patient made a payment prior to submitting an FAP application, excess collected is refunded (unless amount is less than $5.00)

Safe Harbor – Charges in Excess of AGB

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SECOND AUDIENCE POLL QUESTION

Which method does your hospital use (or plan to use) to calculate AGB?

– Look-back

– Prospective

– Unsure

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BILLING AND COLLECTION POLICY

Make Reasonable Effort

s

Determine FAP Eligibility

Extraordinary Collecti

on Actions (ECAs)

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POST DISCHARGE & APPLICATION PERIOD

Extraordinary Collection Actions

Post Discharge Period 1 - 120 Days

240 Days

Application Period 121 – 240 days

First ”Post Discharge” Billing Statement

Reasonable Efforts

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BILLING – POST DISCHARGE 1-120

Reasonable efforts to determine whether a patient is FAP-eligible include:

– A notice informing patients about the availability of financial assistance on billing statements

– In the case of a patient who submits an incomplete FAP application, provide the patient with information relevant to completing the FAP application; and

Reasonable Efforts

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– In the case of an patient who submits a complete FAP application, make a determination as to whether the individual is FAP-eligible; and

– When using Presumptive Eligibility to make a determination follows three specific provisions

Reasonable Efforts

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Conditions that must be met when less than the most generous assistance is provided:

1. Notify patient about the basis for presumptive eligibility determination and how can apply for more generous assistance under the FAP

2. Provide a reasonable period of time for patient to apply for more generous assistance before initiating ECAs to obtain the discounted amount owed for the care

3. Process a complete FAP application by the end of the application period or, in a reasonable time period

Presumptive Eligibility

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• At least 30 days before initiating ECAs:– Written notice to inform the patient about the intended

ECA the hospital may take if they do not submit a FAP application or pay the amount due by a date that is no earlier than the last day of the 120 day period

– Include a plain language summary of the FAP with the written notice

– Make a reasonable effort to orally notify patient

Reasonable Efforts

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• When a patient submits a complete or incomplete FAP application during the application period

• Or when the hospital documents that it met the components of reasonable efforts and the patient does not submit a FAP application by the end of the 120 day period

• If all of the requirements have been met and the patient has failed to submit a FAP application by the end of the 120 day period, the hospital may engage in Extraordinary Collection Actions

Reasonable Effort Met

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BILLING -APPLICATION PERIOD 121-240

• Hospital must accept and process financial assistance applications

• Begins on date care is provided and ends 240th day after first post-discharge billing statement – Certain exceptions for incomplete applications

• ECAs are permitted beginning on 121st day

Reasonable Efforts

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ECAs include action that requires a legal or judicial process that include, but are not limited to:

• Reporting a debt to a credit agency or agencies;• Placing a lien on an individual’s property; • Foreclosing on an individual’s real property; • Attaching or seizing an individual’s bank account or any

other personal property; • Commencing a civil action against an individual; • Cause an individual’s arrest; and • Garnishing an individual’s wages


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APPLICATION PERIOD 121-240 DAYS

• The final rule retained the general rule that the sale of an individual’s debt to another party is an ECA

• If the following conditions are met by the purchaser prior to a sale, then the sale of patient debt is NOT considered an ECA:– Agrees not to engage in any ECAs – Agrees not to charge interest in excess of rate in effect under section

6621(a)(2) at time debt is sold– Debt must be returnable or recallable by hospital– If individual is determined to be FAP eligible and the debt is not

returned or recalled by the hospital, the purchaser must adhere to procedures that the patient pays as FAP eligible


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• Deferring or denying, or requiring payment before providing medically necessary care because of non-payment of previously provided care under the FAP

Extraordinary Collection Actions – New in Final Rule

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Hospital will have made reasonable efforts if:

• Provide a notice about potential ECAs that could be resumed if the application is not completed and the balance is not paid

• Provide an accompanying plain language summary of the FAP

• Provide contact information where they can obtain assistance to complete the FAP application

Processing Incomplete FAP Applications

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Hospital will have made reasonable efforts if:

• ECAs are suspended

• Financial determination is made

• Provides a revised billing notification

• Refunds excess payments (unless less than $5.00)

• Takes all reasonably available measures to reverse ECAs

Processing Completed FAP Applications

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THIRD AUDIENCE POLL QUESTION

Have you made changes to your billing and collection policy to accommodate 501r provisions?

– Yes

– No

– Unsure

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BILLING AND COLLECTION

• Create, revise or establish a compliant billing and collections policy and make certain it is appropriately approved

• Review billing statements

• Review agreements with collection agencies related to ECAs that an agency may take

High Level Tasks


CLOSING THOUGHTS

• Create an internal implementation team

• Develop a timeline for implementation

• Conduct a gap analysis against current policies

• Implement processes to continually monitor ongoing compliance

• Remember to consider potential state laws


QUESTIONS

800.942.2995 x1250

Laurie [email protected]

mailto:[email protected]