Ask the Experts: Determining Patient Financial Assistance Eligibility

We have been trying to consolidate our individual facility financial policies into a single health system financial policy. One of the facilities has a simplified financial assistance application that only asks for income, assets, and household size. Others are asking for monthly household expenses and doing a calculation of disposable income.

One of our facilities was told by a Medicare auditor that you must request information on additional household expenses on a financial assistance application. Another facility was told that you should not request this information if your policy does not require it to determine financial assistance eligibility.

Chapter 3, Section 312, of the Medicare Provider Reimbursement Manual states:

The provider should take into account a patient’s total resources which would include, but are not limited to, an analysis of assets (only those convertible to cash and unnecessary for the patient’s daily living), liabilities, and income and expenses. In making this analysis the provider should take into account any extenuating circumstances that would affect the determination of the patient’s indigence.

I am wondering if other facilities feel that additional household expenses are required to determine financial assistance eligibility. Any guidance would be appreciated.

Answer 1: I feel that the Medicare Provider Manual citation in your question clearly states that all financial considerations should be included.

This question was answered by: Michele Marcum, CHFP, senior network manager, Aetna, and a member of HFMA’s Idaho Chapter.

Answer 2: New York state requires that hospitals keep the questions simple for uninsured patients and focus only on income and household size, not on assets or other information. We comply with that. 

However, we also offer assistance to insured patients who might struggle with their out-of-pocket costs. For that program, we ask for more information including household expenses to determine if we can be more generous and offer greater assistance. There are households that wouldn’t qualify on income alone, but might have expenses related to multiple sick members or expensive prescriptions and would therefore qualify. Many of those qualifying are Medicare patients without supplemental insurance.

This question was answered by: Ruth Landé, senior vice president, patient revenues, Memorial Sloan-Kettering Cancer Center, and a member of HFMA’s Metropolitan New York Chapter.

The information provided through the Forum’s Ask the Expert service does not constitute legal advice, even when the advice is provided by lawyers. You need to obtain your own legal counsel for legal advice, and consider the laws and regulations that govern your state. The content and opinions expressed are those of the Forum experts, and not that of their employers or of HFMA. HFMA does not endorse the material or warrant or guarantee its accuracy. The responses are based only on the specific facts or circumstances provided. Forum experts cannot be held liable for outcomes related to any information provided.

Pose another question to the Forum experts.