HAP 2011 Final Report

The Medical Debt Crisis in Indianapolis: A
Closer Look
Part Two- Financial Assistance Policies
A Report by the Hospital Accountability Project
An Initiative of
Citizens Action Coalition Education Fund
And
Indiana Legal Services
With support from Community Catalyst
EMBARGOED UNTIL WEDNESDAY, JUNE 22 AT 2:00PM

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About the Indianapolis Hospital Accountability Project
The Citizens Action Coalition Education Fund (CACEF) was established in 1976.
CACEF’s mission is “To improve the quality of life of all inhabitants of the State of
Indiana by conducting research, public education and development efforts to conserve natural
resources, protect the environment and provide affordable access to essential human services.”
CACEF is a 501(c)3 organization. Often CACEF partners with the Citizens Action Coalition of
Indiana (CAC), a 501(c)4 membership organization that works statewide on consumer, health
and environmental issues. Over the last thirty years these organizations have contributed
measurably to improving the lives of Hoosiers from all socioeconomic spheres.
Incorporated more than forty years ago, Indiana Legal Services, Inc. (ILS) is the largest
poverty law firm in Indiana, serving clients in all 92 Hoosier counties. Its mission is to provide
poor people with a wide variety of aggressive, quality legal services which will effectively help
them to gain equal access to the courts; empower them to control their lives; and impact on the
major causes of poverty. ILS attorneys provide free legal counsel on a wide range of civil legal
matters; however, consumer law, income maintenance (public benefits) and health care are
among the most often raised.
Community Catalyst is a national non-profit advocacy organization dedicated to making
quality, affordable health care accessible to everyone. Since 1997, Community Catalyst has
worked to build consumer and community leadership to transform the American health system.
With the belief that this transformation will happen when consumers are fully engaged and have
an organized voice, Community Catalyst works in partnership with national, state and local
consumer organizations, policymakers, and foundations, providing leadership and support to
change the health care system so it serves everyone—especially vulnerable members of society.
Community Catalyst’s Hospital Accountability Project works with advocates across the
country to implement state and local hospital practices that regularly involve the community in
health planning, protect families from financial devastation due to medical debt, and allow the
uninsured and underinsured to seek and receive needed health care services. The Indianapolis
Hospital Accountability Project is funded by Community Catalyst. For more information, visit
www.communitycatalyst.org.
The Indianapolis Hospital Accountability Project is a collaborative effort of the
Citizens Action Coalition Education Fund and Indiana Legal Services. This is a second report
following an initial report, which examined the impact of hospital debt and the strength of the
hospital safety net in Indianapolis. This report will focus on the nonprofit hospitals’ financial
assistance policies, how well they are complying with the new provisions under the PPACA, and
best practices they could engage in to better serve the underinsured and uninsured citizens of
Indianapolis.
Hospital Accountability Project: Working to ensure that nonprofit hospitals in
Indianapolis earns the tax breaks they receive by providing an adequate amount of charity care
to underinsured and uninsured citizens.

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Table of Contents
Executive Summary and Recommendations Page 4
Overview of Hospital Meetings Page 7
Overview of State and Federal Law Requirements Page 9
What are nonprofit hospitals’ policies? Page 11
Financial Assistance Policies
Limiting Charges
Billing and Debt Collection Policies
HAP Concerns
Best Practices Page 16
Conclusion Page 26
Appendix I- HAP recommendations from first report Page 27
Appendix II- Financial assistance policies Page 30
Appendix III- Financial assistance adjustment Page 64
tables in relation to the Federal Poverty Guidelines

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Executive Summary and Recommendations
Summary
The Citizens Action Coalition Education Fund (CACEF) and Indiana Legal Services (ILS) began
work on the Hospital Accountability Project (HAP) in 2008 to focus on the issue of medical debt
within Marion County. The goal of the project is to ensure that the four Marion County nonprofit
hospitals earn the tax breaks they receive by providing an adequate amount of free and/or
reduced cost care, often referred to as charity care, to uninsured and underinsured citizens.
Hospital debt is a key element of the medical debt problem facing Marion County residents.
Over the past two years, HAP has worked to improve Indianapolis nonprofit hospitals’ financial
assistance policies to ensure that uninsured and underinsured citizens can access hospital care
without incurring large amounts of debt by: a) identifying residents with significant hospital
debt; b) conducting community meetings to educate these residents of their legal rights and
responsibilities as medical consumers; c) dialoguing and negotiating with the hospitals to
improve their written financial assistance policies and to increase public awareness about these
policies. The Medical Debt Crisis Report, the first issued by HAP, examined how well Marion
County nonprofit hospitals are fulfilling their charitable mission. HAP conducted a study from
September 2009 through June 2010 and found that health insurance does not necessarily protect
one from hospital debt and that half of people surveyed were unaware of financial assistance
programs available. These findings support much of what has been reported nationally: in
Indiana, hospital charity care is a secret to many patients who are truly in need of safety net
services. This demonstrated that improvements must be made and Indianapolis nonprofit hospital
financial assistance programs should not be a “best kept secret.”
To challenge the “best kept secret,” over the past 18 months, the Hospital Accountability Project
has partnered with community organizations and conducted neighborhood meetings where an
ILS attorney educated people on their rights and responsibilities as medical consumers. These
instructional forums have produced scenarios where people have discovered significant errors in
their hospital bills, negotiated arrangements to repay the outstanding debt without aggressive
collection actions taken, and in several cases, received financial assistance after attending one of
our meetings and knowing what to ask. The HAP staff has also met with key administrators at
the county’s nonprofit hospitals to share consumer stories collected at our community meetings
and to discuss their financial assistance policies. The Patient Protection and Affordable Care
Act (PPACA) made some important changes to laws regarding financial assistance/community
benefits and while regulations and details have yet to be issued, this presented an opportune time
to provide feedback to hospitals and encourage them to comply with the new law in a way that
will most help consumers.1
While the hospitals shared their well-intentioned practices and procedures, the lack of knowledge
among the public about available help raises the issue of this glaring disconnect between a
hospital’s written policy and how that policy is implemented. This is a critically important issue

1
HAP recommendations from the initial report are provided in Appendix I.

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since failure to adequately notify the public and implement the law could lead to revocation of
nonprofit hospitals’ tax-exempt status.
Overall, these initial meetings were constructive, positive, and were usually met by hospital
administrators with open attitudes and a desire to learn more about ways they may be able to
improve their policies and procedures to better protect vulnerable consumers. From information
received in our face-to-face meetings with hospital administrators and after carefully analyzing
the financial assistance policies, our review indicates that IU Health has the most comprehensive
written financial assistance policy.
St. Francis Hospital has the dubious distinction of having the least comprehensive financial
assistance policy. This is troubling because our interactions with St. Francis Hospital
representatives have been disappointing. Perhaps it is because their corporate headquarters are
located in Northern Indiana, but our initial meeting with them yielded few answers and little
willingness to engage in dialogue about improving their charity care and financial assistance
policies. Much of our consumer outreach has been focused on the south side of Indianapolis, St.
Francis’ main service area, so we have heard numerous horror stories about their harsh collection
practices and failure to provide information about financial assistance to those in need. We are
concerned that a lack of local decision-making is preventing St. Francis patients in Indianapolis
from getting the help they need.
This second report will examine in detail the four nonprofit Indianapolis hospitals’ (St. Vincent
Health, Sister of St. Francis Health Services, Community Health Network, and IU Health)
financial assistance policies by looking for compliance with the basic provisions under the
PPACA and using Community Catalyst’s Patient Financial Assistance Model Act as a guide for
best practices that will most benefit vulnerable consumers.
Recommendations
The language in the PPACA regarding hospital financial assistance policies is vague and needs
further clarification through rulemaking. In the meantime though, hospitals are reworking
policies and we encourage them to take this opportunity to build a stronger safety net that will
protect more Hoosiers. Along with the initial recommendations presented in our first report
regarding notification, billing practices and measures to publicize financial assistance programs
outside the hospital walls; HAP has further recommendations.
Eligibility Categories:
1. The financial assistance policies should include full free care, partial free care, and
medical hardship categories.
A. Full Free Care- Provided for those with incomes at or below 200% FPL with no asset
test
B. Partial Free Care- Provided for those with incomes at 201%-400% FPL with no asset
test, based on a sliding fee scale.
C. Medical Hardship- Provided for those whose hospital bills exceed 25% of the
family’s annual income with assets that cannot cover the amount. Primary home and
vehicle may not be considered.

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Notification and Application Process:
1. Staff working in the relevant areas such as admissions, billing departments, emergency
rooms, and neighborhood clinics should be consistently and regularly trained on the
hospital’s financial assistance policy. They should be able to explain information about
the programs and assistance the hospital offers and direct the patient to someone who will
further assist them with questions. There should also be financial assistance applications
available at each of these areas for staff to provide.
2. Screening for the uninsured and underinsured should occur at the point of service or at
the front end of the hospital experience.
3. The policy must state how hospitals provide assistance in the application process.
A. Documentation- Social Security Numbers should not be required. Assets should not
be considered for full and partial free care.
B. Timing-Once an application has been submitted, hospitals should determine
eligibility within 14 days. The patient’s account should be placed on hold during this
period.
Limiting Charges:
1. The amount owed by the uninsured should be calculated at the lowest rate paid by
Medicare or Medicaid or the actual unreimbursed cost to the hospital for that particular
service determined by the cost-charge ratio.
Debt Collection:
1. Payment plans should only be offered after determining that a government assistance
program and/or financial assistance do not apply.
2. Those who qualify for government programs or financial assistance should be exempt
from debt collection activity.
3. Accounts submitted to collection agencies that are later found to be eligible for financial
assistance should be given the appropriate level of financial assistance. The hospital
should also be required to refund any money the patient may have already paid on the
account.
4. If collection actions are taken, the highest levels of hospital leadership should be
engaged.
5. Any third party the hospital contracts with or uses in the collection process should abide
by the same collection policy the hospital has in place.

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Overview of Hospital Meetings
HAP began meeting with the nonprofit hospitals in September 2010 to initiate a dialogue about
their financial assistance policies as well as share the findings from our first report and offer
suggestions and recommendations to better address the medical debt crisis in Indianapolis. To
help provide a face to this problem, HAP also shared numerous consumer stories collected at our
community meetings. They all included a common theme: people without the means to pay their
hospital bills were never informed by hospital personnel of any financial assistance programs.
This lack of information is a critically important issue since failure to adequately notify the
public and implement the law could lead to revocation of nonprofit hospitals’ tax-exempt status.
The initial meetings also provided HAP with an opportunity to hear from the hospitals about
their current practices and focused mainly on areas of notification within the hospital, eligibility
requirements, assistance in applying for financial assistance, billing and debt collection practices,
as well as efforts to publicize their policies to the communities they serve. While the hospitals
shared their well-intentioned practices and procedures, the lack of knowledge among the public
about available help raises the issue of this glaring disconnect between a hospital’s written policy
and how that policy is implemented. Overall these initial meetings were constructive, positive,
and were usually met by hospital administrators with open attitudes and a desire to learn more
about ways they may be able to improve their policies and procedures to better protect
vulnerable consumers.
In advance of scheduling follow-up meetings, HAP requested the financial assistance policies
from each of the four nonprofit hospitals, in order to determine how well their policy matches up
with our recommendations. We were disappointed in the length of time it took the hospitals to
fulfill our request. The lack of response by St. Francis to a number of communications made it
necessary to send a certified letter asking for the policy, which hospital representatives had
initially agreed to provide. However St. Vincent, IU Health, and St. Francis all stated the delay
was due to revisions and updates being made to their policies as a result of the new law. HAP
appreciates the hospitals’ efforts to comply with the new federal provisions and the open lines of
communication put forth by Community, St. Vincent, and IU Health. Community Hospital was
the first to send their policy and thus the first to begin meeting with HAP to answer specific
questions. IU Health was next, followed by St. Vincent and finally St. Francis. For the purpose
of this report, the analysis will be based on the current hospital policies and a separate section
will be provided discussing what updates and revisions the hospitals say they are in the process
of making.
From information received in our face-to-face meetings with hospital administrators and after
carefully analyzing the financial assistance policies they provided to us upon request, our review
indicates that IU Health has the most comprehensive written financial assistance policy.
St. Francis Hospital has the dubious distinction of having the least comprehensive financial
assistance policy. This is troubling because our interactions with St. Francis Hospital
representatives have been disappointing. Perhaps it is because their corporate headquarters are
located in Northern Indiana, but our initial meeting with them yielded few answers and little
willingness to engage in dialogue about improving their charity care and financial assistance

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policies. Much of our consumer outreach has been focused on the south side of Indianapolis, St.
Francis’ main service area, so we have heard numerous horror stories about their harsh collection
practices and failure to provide information about financial assistance to those in need. We are
concerned that a lack of local decision-making is preventing St. Francis patients in Indianapolis
from getting the help they need.
Charles’ Story
Charles Melton went in for two surgeries at St. Francis Hospital on April
14, 2010. Charles, 62, and his wife, 70, started receiving the bills a month
later. Due to their inability to pay the bill, Charles called the 1-800
number listed on the bill for help. He received the application for financial
assistance in the mail from Hammond, Indiana and sent in the correct
documentation including income and assets. Charles did not receive any
word from St. Francis until the end of July 2010. Instead of informing him
about his eligibility for charity care, he got a bill demanding payment,
stamped FINAL NOTICE. His wife called to set up a payment plan of
$226 per month and despite their earlier application for financial
assistance, the billing agent never mentioned the possibility of any help.
Charles and his wife paid $226 monthly until January 2011, when ill health
forced Charles to retire and their already modest income plunged. They
never got any response to their April 2010 request for financial assistance.
Charles and his wife first learned about the hospital’s legal responsibility
to provide financial assistance/charity care at the Hospital Accountability
Project community meeting in April 2011. They were able to learn more
about their rights and responsibilities as medical consumers and felt better
equipped and educated to know what to ask for when talking with St.
Francis. Charles called the hospital back informing them of his presence at
the community meeting and asked for information on charity care. Even
then, Charles was continually pressured to set up another payment plan,
but remained persistent in asking about charity care. The billing
representative finally stated that papers would be mailed to his house, but
he informed her that he had already filled out an application. After going
back and forth, he agreed to have the papers mailed to him again, but after
about a week there was still nothing in Charles’ mailbox. He called back
and talked with a different representative. This representative, after asking
a supervisor, told Charles another of set of papers would be mailed to him
and that his previous application had been destroyed after six months.
Charles was also asked to send in a payment. The application arrived three
days later and Charles promptly returned it with all the information
requested.
Three weeks later St. Francis notified Charles via mail about a missing
signature on his application. He was told to resubmit a copy of all the
original tax forms. These were included in the first application sent, but
Charles was told to mail those back in by June 17th
. No explanation was
given as to why he needs to repeat this, and he is getting frustrated.

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Overview of State and Federal Law Requirements

Both Indiana and federal law set requirements for nonprofit hospitals to provide financial
assistance.2
For example, Indiana’s law (IC 16-21-9) sets parameters and requirements that
nonprofit hospitals must meet for providing free and/or reduced cost care to patients, conducting
community assessments to identify health care needs, creating community benefit plans for
meeting those needs, evaluating the effectiveness of the community benefit plan, and also
providing public notification through prominent postings within the hospital including the
emergency room, waiting area, and the admission office waiting area.3
In addition to state law, the recently passed PPACA adds new standardized IRS reporting
requirements that nonprofit hospitals must meet to keep their federal tax-exempt status. The new
reporting standards and financial assistance provisions serve as another important step towards
cracking open “the best kept secret.” Through the IRS and new Schedule H that hospitals will be
required to complete beginning next year, important information will now be made available to
the public giving communities better insight on hospital budgeting and finance, policies on
billing and debt collection, and financial assistance. The Secretary of the Treasury will receive
audited financial statements from the hospitals along with the Schedule H where hospitals must
report information on levels of bad debt, charity care and unreimbursed costs from government
programs for all hospitals as well as community benefit costs borne by private nonprofit
hospitals. These reports will be reviewed and given to Congress every year. The Secretary of
the Treasury will be charged with reviewing each hospital’s community benefit activities every
three years.4
Specifically, Section 9007 of PPACA amends section 501(c)3 of the Internal Revenue Code by
adding four new conditions hospitals must meet to qualify as tax-exempt under the federal tax
code.5
The hospitals must:
1. Develop written financial assistance policies, which must state:
o Whether they offer free or discounted care
o Eligibility criteria for receiving financial assistance
o The basis used to decide how much patients are charged for care
o A description of how to apply for financial assistance

2
Financial assistance is commonly referred to as Charity Care and Community Benefits. For the purpose
of this report, financial assistance will be substituted for both.
3
IC 16-21-9-1 – 16-21-9-8 (1994) http://www.in.gov/legislative/ic/code/title16/ar21/ch9.html
4
“Protecting Consumers, Encouraging Community Dialogue: Reform’s New Requirements for Non-
profit Hospitals” page 4-5. Community Catalyst, May 2010.
http://www.communitycatalyst.org/doc_store/publications/Hospital_Accountability_Summary_ACA.pdf
Accessed April 2011.
5
“Protecting Consumers, Encouraging Community Dialogue: Reform’s New Requirements for Non-
profit Hospitals.” Community Catalyst, May 2010.
http://www.communitycatalyst.org/doc_store/publications/Hospital_Accountability_Summary_ACA.pdf
Accessed April 2011.

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o Steps the hospital might take to collect payments, unless the hospital already has a
separate billing/debt collection policy in place
o Measures to publicize the policy widely in the community the hospital serves
2. Limit what they charge for services:
o Hospitals are prohibited from using “gross charges.” The term “gross charges” is
not defined by law but is generally accepted to mean the hospital’s list price for
services without any negotiated discounts.
o If a patient qualifies for financial assistance and is in need of emergency or other
medically necessary care, he or she may only be charged the “amounts generally
billed” to insured patients for the same services.
3. Observe fair billing and debt collection practices.
o Nonprofit hospitals need to make a “reasonable effort” to determine if a patient
qualifies for financial assistance before pursuing “extraordinary” debt collection
activities.
4. Conduct regular community needs assessment at least every three years, seek input from
community members, make the assessments available to the public, and adopt strategies
for meeting needs identified.6

6
Unlike the other requirements that were effective March 23, 2010, the Community needs assessment
will be effective after March 23, 2012.

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What Are the Hospitals Doing?
Financial Assistance Policies:
IU Health (IUH)
 Full free care is available to patients with income levels at or below 200% of the FPG.
 Partial free care is available to patients with income levels between 201%-400% of the
FPG, based on a sliding fee scale.
 Partial free care ends at 400% of the FPG for insured patients.
 Partial free care is available for uninsured patients above 400% of the FPG, based on a
sliding fee scale. This ends once the amount has exceeded the uninsured discount of 40%
already given by IUH.
 Eligibility for financial assistance is based on income and family size.
 A description of how to apply for assistance is provided along with necessary
documentation to complete an application.
 Patients are responsible for initiating the financial assistance process. After receiving the
application, the patient has 21 calendar days to return it.
 IUH allows 90 days to issue a determination.
 A written request may be submitted, along with supporting documentation, if a patient
wants to appeal the financial assistance determination.
 There is no detail regarding billing and debt collections, unless IUH has a separate billing
and debt collection policy in place. HAP has asked, but does not know the current status
on this policy.
 There are no measures stated in the financial assistance policy to publicize the policy
widely in the community.
Community Health Network (CHN)
 Full Free Care is available to those with income levels at or below 200% of the FPG.
 Eligibility for Full Free Care is based on family size, income, and whether the patient has
other financial resources.
 Partial Free Care will be considered for those above 200% with medical bills that exceed
25% of family income.
 The discount may be given depending on the patient’s circumstance and a financial
assistance representative will determine the amount.
 The policy describes how to apply for financial assistance.
 Efforts to determine eligibility are made on the front-end of patient’s hospital stay.
 Patients are given 15 calendar days from the initial date of request to submit a financial
assistance application. A 15-day extension is offered.
 CHN allows 30 business days to issue a determination.
 Patients may appeal the decision in writing and include the basis for the appeal.
 There is very little detail about billing and debt collection in the CHN policy, but it is
unclear whether or not CHN has a separate billing and debt collection policy.
 CHN also fails to describe any measures they are taking to publicize the policy widely in
the community.

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St. Vincent Health (SVH)- After some initial confusion about what information we were
requesting, SVH shared their corporate parent’s Billing and Collection for the Uninsured Policy
with us. The policy given does address financial assistance, but its wording leads us to believe it
is limited to uninsured patients only. HAP is waiting on clarification as to whether this policy
extends to patients with health coverage. SVH stated they are continuing to make revisions and
will have an updated policy out by the first of their fiscal year, July 1, 2011.
 Full Free Care is available to those with income levels at or below 200% of the FPG.
 Partial Free Care is available to those with income levels between 200%-300% of the
FPG, based on a sliding fee scale.
 The amount of financial assistance given is based on income and may be adjusted by the
hospital for the cost of living in that particular area.
 Patients above 300% of the FPG will be eligible for a medical hardship discount.
 This is based on their ability to pay, issuing a “Means Test” which considers income,
medical bill obligations, mortgage payments, utility payments, number of family
members, and disability considerations.
 A description of how to apply for financial assistance is lacking in the policy.
 As this policy is specifically for billing and collections, this analysis will be picked up in
following section.
 Measures taken by SVH to publicize the policy widely in the community is also lacking
in the policy.
Sisters of St Francis Health Services (SSFHS)
 Full Free Care is available to those with incomes at or below 200% of the FPG.
 Partial Free Care is available to those with incomes between 201%-300% of the FPG,
based on a sliding fee scale.
 The amount of financial assistance given is based on family income and available assets.
 Patients may apply for financial assistance by calling the number provided on posted
notices throughout the hospital or going onto the website.
 In a separate Patient Financial Policy, SFH states the registrar will screen the patient for
insurance and then against the Medicaid database.
 For uninsured patients, the registrar discusses possible payment arrangements. The
registrar, at their discretion, first discusses bank loan information and then whether the
patient qualifies for Medicaid. Financial assistance is offered once those options have
been exhausted.
 Uninsured patient accounts under $2000 are not screened for possible coverage by
government programs.
 The billing process is briefly outlined in the CBO Patient Financial Policy.
 There is no mention of measures the hospital is taking to publicize the policy widely in
the community.

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Limiting Charges for Self-Pay: Under the PPACA, hospitals are uniformly prohibited from
using “gross charges” and may only charge patients the “amounts generally billed” to insured
patients for the same services.7
IUH
 IUH has a separate Adjustment for Uninsured Patients Policy that does prohibit the
hospital from using gross charges for uninsured patients.
 The policy determines the adjustment by averaging the “three best negotiated Managed
Care rates.”8
This is calculated annually. For 2011 the amount comes to 40% of gross
charges.
CHN
 Patients are given a discount from gross charges with varying percentages according to
the facility and service. Discounts for the uninsured at the hospital are 30%. However,
the policy does not describe the basis for the charge or how discounts are calculated.
SVH
 SVH offers uninsured patients with the ability to pay a discount based on the discount
provided to the highest-paying private payer.
 If the highest-paying private payer does not account for at least 3% of the hospital’s
business for that given year, more than one payer contract will be averaged to reach 3%
of hospital business.
SSFHS
 SFH offers a 20% discount of billed charges to eligible uninsured patients.
 It is unclear what constitutes eligibility in this section.
 What the discount is based on is also unknown.
Billing and Debt Collection Practices: The new law prohibits hospitals from engaging in
“extraordinary collection actions” before making a “reasonable effort” to determine whether a
person qualifies for financial assistance.9
IUH
 IUH policy states it will make reasonable attempts to determine eligibility for financial
assistance before assigning the account to a collection agency or before engaging in
“extraordinary collection actions.”
 If IUH finds it necessary to pursue further collection actions Section V(e) reads, “…IUH,
and its contractors, will engage in fair, respectful and transparent collection activities.”10

7
“Protecting Consumers…” page 3.
8
Indiana University Health. Adjustment for Uninsured Patients Policy. #87, page 2. Next review: 16
December, 2013.
9
“Protecting Consumers…” page 4.
10
Indiana University Health. Financial Assistance Policy. # 88, page 3. Next review: 16 December, 2013.

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 Regarding financial assistance applications, IUH may include a description of the policy
with all patient bills and statements and may suspend collections activities on that
account while an application is being processed.
 Payment plans are not offered for bills below $240, regardless of income.
 HAP did inquire about a separate billing and collection policy and is waiting for a
response from IUH on the status of that policy.
CHN
 CHN does not have adequate detail in the written policy regarding whether the hospital
engages in “fair” billing and debt collection practices.
 If a patient’s account is sent to collections and later found to be eligible for financial
assistance, the amount will be written off to charity care. If the collection agency has
incurred attorney fees, the patient will be held responsible for those charges.
 However, if a patient has made a payment on an account and qualifies for free care, CHN
“is not obligated” to refund the payments already made.
 It is unclear, at this time, whether or not CHN has a separate billing and debt collection
policy in place.
SVH
 SVH’s Billing and Collection for the Uninsured Policy states, “All billing and collection
practices will reflect our commitment to and reverence for individual human dignity and
the common good…”11
 SVH further states that outstanding balances “are pursued fairly and consistently.”12
 SVH does permit liens to be taken out on personal residences if the patient is not making
payments on the payment arrangement and did not qualify for financial assistance.
 Liens are not permitted if they will result in foreclosure.
 Wage garnishments are permitted if a person did not qualify for financial assistance and a
court determines that wages are sufficient.
 The executive management of the hospital must approve the lien as well garnishments
pursued by a collection agency or other representative of the hospital.
 There are also assessments for interest charges on outstanding balances.
SSFHS
 Payment options include cash, check, money order, credit card, bank financing, and
payment plans up to 12 months.
 An account is turned over to collection after four sent statements.
 Patients can still apply for financial assistance once the account has gone to collections.
 If a patient account has been turned over to SSFHS’s collection agencies and thought to
be bad debt, but after review is eligible for free care, the patient may be asked to provide
some documentation for the financial assistance process.

11
Ascension Health. Billing and Collection for the Uninsured. #16, page 1. Effective 1 July, 2004.
Revised 8 June, 2006.
12
Ascension Health… page 2.

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 Documentation they may request is not outlined in the policy.
 There is no further information on SSFHS’s billing and debt collection policy and
whether they comply with “fair” practices.
Our Concerns: Our review of the financial assistance policies indicates a number of areas
where hospitals need improvement to comply with the PPACA. The St. Vincent Billing and
Collections policy does address important issues regarding billing and debt collection, but does
not adequately meet the language of the PPACA, failing to mention safety net services for those
who are insured and/or underinsured. Failing to develop a policy for these patients, who
constitute a large percentage of those with hospital debt, leaves them exposed to unnecessary
financial hardship. All four nonprofit hospitals should describe how the hospital publicizes its
policy in the community. With the exception of St. Vincent, it appears the hospitals need to
develop a billing and debt collection policy if they do not intend to include it in their financial
assistance policy. In our meetings with Community, they did inform us that the discount of the
charge to the uninsured is based on an average of all commercial payers. However, Community
and St. Francis should indicate in their policy the basis for the charge that is being discounted.
New language and detail are needed in St. Francis’ and St. Vincent’s policy with regard to the
application process.

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Best Practices
The new requirements and reporting standards in the PPACA are an important first step towards
addressing the unmet needs of underinsured and uninsured citizens with hospital debt. With
increased oversight of their financial assistance policies and billing and collection practices, the
new regulations provide a level of accountability that has been lacking for nonprofit hospitals.
The new requirements also add an important level of transparency to an inconsistent, complex
system that has exposed millions of vulnerable consumers to unnecessary harm. With
commitment and a collaborative effort toward implementing these basic provisions, nonprofit
hospitals will fulfill their role and responsibility as charitable organizations and as a vital actor in
an ever-changing health care system. Safety-net services will remain important for those who,
even with future health policy changes, may find services unaffordable.13
However, while the new requirements are welcome, more must be done to ensure hospitals are
effectively serving patients in need. HAP has several recommendations or best practices that
hospitals should implement to provide vulnerable consumers with the most meaningful
protections.
ELIGIBILITY CATEGORIES:
Full Free Care, Partial Free Care, Medical Hardship Eligibility
It is important that eligibility for financial assistance be based on family income and not the
amount of a bill. The financial eligibility criteria based on the FPG should be used as floors
only. Hospitals should take into account the area served and cost of living. Anyone whose
income falls at or below 200% of FPG should be given full discharge of debt and a sliding fee
scale should be applied to those whose income is from 201%-400% of FPG. For full and partial
free care, hospitals should only look at family income and not take assets into account. People
at this income typically don’t have many assets and it can be inefficient for hospitals to pursue
this action since it is unlikely to be successful. Medical hardship should be available for those
above 400% of FPG and whose medical bills threaten the patient’s financial stability. A
patient’s medical bills must exceed 25% of family income and have insufficient assets to cover
the amount in order to be eligible. Primary home and vehicle valuation should not be included in
an assets test as this can create an unnecessary burden on the family leaving them with no
financial cushion.14

13
Lemmerman, J. “Does Your Local Hospital Make the Grade on Community Benefit? Now There’s a
Way to Tell.” The Community Catalyst Blog. 12 May 2011.
http://blog.communitycatalyst.org/index.php/2011/05/12/does-your-local-hospital-make-the-grade-on-
community-benefit-now-there’s-a-way-to-tell/ Accessed May 13, 2011.
14 “The Patient Financial Assistance Act,” page 9-11. Community Catalyst, May 2004.
http://www.communitycatalyst.org/doc_store/publications/model_act_and_guide_may04.pdf Accessed
April 2011.

17
Analysis of Eligibility Categories by Hospital
IU HEALTH
COMMUNITY HEALTH NETWORK

PRO
 Full free care is available to patients at or
below 200% of the FPG.
 Eligibility for financial assistance is based
on family size and income.
 Medical Hardship may be available for
patients who do not qualify for full free care
and have debts equal to or greater than 25%
of family income.
CON
 Assets are looked at to determine eligibility
for full free care.
 There is no mention of partial free care for
patients with incomes between 201%-400%
of the FPG.
 For medical hardship, the patient may be
given a discount, which is at the discretion
of the financial assistant representative.
 Assets evaluated for this section are unclear.
 There is no detail as to guidelines the
financial assistance representative follows to
determine eligibility for medical hardship.
PRO
 Partial free care is available to available
between 201%-400% of the FPG.
 Medical hardship is available to
uninsured patients with incomes that
exceed 400% of the FPG.
 Eligibility for financial assistance is
based upon income and family size.
 During our meetings, IUH did state they
will be updating their medical hardship
policy and will consider not looking at
primary home in an assets test.
CON
 Medical hardship is not available to insured
patients above 400% of the FPG.
 Regardless of income, for accounts in excess
of $60,000, a credit and asset test may be
used to determine eligibility and amount.
 The valuation of home and real estate is
included in an assets test.

18
ST. VINCENT HEALTH
SVH policy is specific to uninsured patients only.
SISTERS OF ST. FRANCIS HEALTH SERVICES

PRO
 Full and partial free care is based on income
and may be adjusted by the hospital for that
area’s cost of living.
 They are in the process of updating and
revising their policy, piloting programs such
as a catastrophic/medical hardship category.

CON
 Partial free care is only available to patients
with incomes up to 300% of the FPG, based
on a sliding fee scale.
 For those above 300% of the FPG, partial
free care is only available to uninsured
patients. Eligibility is determined by
assessing a patient’s ability to pay based on
eligible assets and eligible income. Little
detail is provided.
PRO
 Full and partial free care is based on income.
CON
 Partial free care is only available for patients
with incomes up to 300% of the FPG, based
on a sliding fee scale.
 Full and partial free care is based on
available assets.
 Medical hardship is mentioned but not
detailed in the policy.

19
NOTIFICATION AND APPLICATION PROCESS
Our research and conversations with consumers indicate that public notification about financial
assistance within the hospitals is insufficient. Information about financial assistance should be
provided at multiple points and times during a patient’s visit. Along with visible and easy to
read signage in prominent locations inside the hospital and all outpatient clinics and postings on
the website, it is even more impactful when staff is properly trained and informs a patient of the
hospital’s financial assistance policy and programs. Also, signs in the hospital, information on
the website, and applications should be available in multiple languages.15
Unfortunately, our research has found that notwithstanding their written policies regarding
notification and signage, the nonprofit hospitals in Indianapolis are not doing an adequate job of
posting information about charity care and financial assistance. It is disappointing they have not
improved these practices since our first report, because notification within the hospital and on a
website is the easiest way to provide the information. While hospitals must improve their
community outreach as well, better signage and brochures and more accessible websites should
be the first step taken to better inform patients in need of help. We have identified numerous
consumers through our meetings and surveys who have avoided seeking needed care because of
fear about not being able to pay the bill; this situation would be significantly reduced if hospitals
did a better job of informing patients about the availability of financial assistance.
Screening uninsured and underinsured patients for financial assistance should occur at point of
service or the front end of the hospital experience. The process should first check for eligibility
for public or private enrollment in a health plan. This will help avoid patients from being
embroiled in the collection process only to find out they were eligible for assistance.
When a patient is eligible for financial assistance or some other form of coverage the hospital
should provide assistance in the application process. In order not to deter those from seeking
necessary medical care, especially undocumented immigrants, documentation such as social
security numbers should not be required and for those receiving full or partial free care, no assets
should be reviewed. Once applications are submitted, hospitals should make timely decisions,
within 14 days, of approval or denial and place the patients account on hold while the application
is being processed.16
Overall, hospitals need to assume a larger share of responsibility for
aggressively promoting financial assistance programs. Through front-end screening, aggressive
notification and implementation, and assistance with the application process hospitals will
become more efficient with their resources and patients will avoid unnecessary hardship.

15
“The Patient Financial…” page 29.
16
“The Patient Financial…” page 12-13.

20
Analysis of Notification and Application Process by Hospital
IU HEALTH

PRO
 Financial assistance notification, the
policy, and application are available on
the website.
 After a significant rebranding
transformation IUH has new documents,
brochures, and signs that will be
implemented soon to better promote
their financial assistance programs.
They are also working to have the
information available in Spanish.
 Every uninsured person will be mailed a
financial assistance application.
CON

 Signage and notification are not prominent
throughout the hospital.
 Alternative language availability and
simplicity of language are an issue.
 A description of the policy may be included
with all patient’s bills.
 The onus remains on the insured and
underinsured to ask for assistance.
 A patient is given 21 days to submit an
application while the hospital has 90 days to
make a determination on the financial
assistance application.
 The application takes into account assets
such as the primary home and vehicle.
 The policy does not state if an account is
placed on hold during this period.

21
COMMUNITY HEALT NETWORK
ST. VINCENT HEALTH

PRO
 In the three past due notices sent to patients,
financial assistance is mentioned.
 Patients who are “likely to qualify” for
financial assistance, determined through a
third-party vendor, automatically receive the
appropriate level of financial assistance.
 Patients are given 15 calendar days and may
ask for an extension of another 15 days to
submit an application.
CON
 Brochures and posters should include a
contact person or number for patients to call
for assistance.
 There is no information on the website about
financial assistance.
 Financial assistance applications are not sent
with the three past due notices.
 Financial assistance application is the most
rigorous and extensive of the four hospitals.
 The policy does not state if an account is
placed on hold during this period.
 CHN has 30 business days to make a
determination on the financial assistance
application.
PRO
 Brochures do provide detail on financial
assistance and include an application.
 At our meeting, determining eligibility at the
point of service was stressed along with staff
training and an openness to discuss and
exchange ideas on signage.
 SVH is in the process of issuing policy
updates regarding point of service
counseling, inpatient evaluation of need for
financial assistance, and increasing patient
engagement.
CON
 Financial assistance information is not
available on the website.
 There is no detail on the application process.

22
LIMITING CHARGES:
In the new law, further clarification on specific terms like “gross charges” and “amounts
generally billed” have yet to be defined. Therefore, this part of the law fails to ensure what the
law intended; that uninsured hospital patients are charged at the lowest rate. It is recommended
that hospitals calculate the amount owed by uninsured patients at either the lowest rate that
would be paid by Medicare or Medicaid, or the actual unreimbursed cost to the hospital for that
particular service determined by the cost-to-charge ratio.17
While the Marion County nonprofit
hospitals are giving discounts to the uninsured, none of the hospitals calculate the amount at the
lowest rate that is paid to the hospital.
BILLING AND DEBT COLLECTION
Best practices for this section are intended to preserve the right of hospitals to pursue payment
for services while at the same time protecting consumers from unfair practices. Two important
parts of this section are debt collection practices that are prohibited and whether third party
vendors are held to the same restrictions as the hospitals with which they contract. Patients who

17
“Re: Notice 2010-39 (New Requirements for Tax-Exempt Hospitals),” page 3-4. Community Catalyst,
21, July 2010. http://www.communitycatalyst.org/doc_store/publications/IRS_Sign-
on_Letter_RE_Nonprofit_Hospitals_with_sign_ons.pdf Accessed March 2011.

PRO
 Financial assistance information along
with an application are provided on the
website.
 SSFHS does not ask for documentation
of the primary home and vehicle in
determining assets in the financial
assistance application.
 According to email correspondence, an
account is placed on hold for 30 days
while being processed and will remain
on hold until a determination is made.
CON
 Implementation concerns are similar to the
other hospitals regarding signage and
notification.
 Only uninsured patient accounts over $2000
are screened for possible coverage by State
or Federal programs.
 There are no further details with the
application process.

23
qualify for financial assistance, are eligible for government programs, or have pending financial
assistance applications should be exempt from debt collection activity. If a hospital does engage
in aggressive collection action on a patient’s account, the highest levels of leadership at the
hospital should be fully engaged and required to sign off on the collection. Accounts that are
already involved in collection actions, but are found to be eligible for free care should receive a
refund for any money they may have already paid.
For billing payment plans, pressure should not be applied to a patient to enter into a plan before
eligibility for a government program or determination of financial assistance. If a patient does
enter into a payment plan, arrangements should take into account a patient’s income and other
financial responsibilities. Hospitals should also inform patients about general information on the
difference between the interest rate it charges and the rate charged by credit card companies and
banks that finance consumer debt.18
Analysis of Billing and Debt Collection Policy by Hospital
IU Health

18
“The Patient Financial…” page 13-14.

PRO
 IUH has a new consolidated statement plan,
combining billing for hospital services and
physician practices/groups with one phone
number to call for questions.
 According to our meetings, a total of 7
notifications are made via mail and phone
about payment on a bill before the account
is sent to collections.
CON
 A description of the policy may be
included with all patient bills and
statements.
 Payment plans are not offered for bills
below $240.
 There is no mention of an account being
placed on hold while a determination is
being made for financial assistance.
 At this time, a separate billing and debt
collection policy does not exist to clarify
and further explain these issues.

24
COMMUNITY HEALTH NETWORK
ST. VINCENT HEALTH

PRO
 The language in the policy about pursuing
outstanding balances adheres to the PPACA.
 Payment arrangements are offered to
uninsured patients who do not qualify for
 Information about the difference in interest
charges is addressed in certain situations.
 In the meetings, SVH stated they have
interest free payment plans up to 120
months.
 Upper level management must sign off on
collection practices that include lien and
wage garnishments.
 Collection agency agreements must be
signed by contractors for compliance of
SVH billing and debt collection practices.

PRO
 In order to comment more on billing and
debt collections for CHN, a separate policy
or more information in the financial
assistance policy is needed.
CON
 The financial assistance policy provides
little detail about billing and debt collection.
 It is unclear whether CHN has a separate
billing and debt collection policy.
 CHN has no obligation to refund payments
made on an account to patients who later
qualify for financial assistance.
CON
 The policy only extends to the uninsured
and offers no protection for the insured and
underinsured.
 Collection practices do include lien and
wage garnishments.

25

PRO
 A written notice will be provided on the
billing statement about the availability of
 Through email correspondence SSFHS
stated that all patients are offered interest
free payment plans up to one year.
 Patients can apply for financial assistance
once the account has gone to collections.
 Accounts sent to collection agencies will be
reviewed to identify amounts originally
thought to be bad debt, but that qualify for
CON
 There is no detail or explanation about what
is included on the statement or a financial
assistance application attached.
 Uninsured patients are offered financial
assistance only after other possible payment
arrangements are discussed including bank
loan information.
 4 options are given to patients paying.
Financial assistance is not included.
 Patients receive a total of 4 statements
before an account is sent to collections.
 Patients with accounts sent to collections
that are later found eligible for financial
assistance may be requested to provide
documentation. No details are provided.

26
CONCLUSION
It is encouraging to see that the nonprofit hospitals are including some of the “best practices” in
their financial assistance policies. However, from our research and conversation with
consumers, it is clear there is a disconnect between the policies and the implementation of those
policies. From our ongoing dialogues with the hospitals, we are hopeful that improved and
updated policies will include medical hardship programs; more consistency and adherence to the
law regarding signage and public notification; details about and assistance with the application
process and fairer debt collection practices.
Our primary concern with nonprofit hospitals and financial assistance has not changed since our
first report: They are not doing an adequate job in informing their patients, or the public, about
charity care and financial assistance. While the new requirements under the PPACA are well
intentioned, in order for consumers to really benefit they have to be informed about these
programs. Additionally, hospitals tend to focus their charity care outreach on the uninsured,
leaving many underinsured consumers vulnerable. Our research indicates the majority of
consumers with hospital debt had insurance, so this focus is misplaced and must be re-examined.
At best, the inadequacies in the Marion County nonprofit hospitals’ charity care programs
prevent them from completely fulfilling their charitable missions. At worst, they are
disregarding the law and IRS regulations, cheating taxpayers and putting their nonprofit status at
risk. We hope the hospitals will continue to work with us to improve their policies and increase
public awareness about them to ultimately decrease the number of families in our community
devastated by hospital debt.

27
Appendix I
HAP Recommendations from, “The Medical Debt
Crisis in Indianapolis: A Snapshot”

28
HAP RECOMMENDATIONS
Public Notification
1. Information that services are available at no or reduced cost must be clearly posted in a
variety of places throughout the hospital, on the hospital website, and throughout the
community. This should include:
a. Posted in all waiting rooms
b. Provided verbally and in writing at the time an individual registers or pre-registers with
the hospital.
c. Provided verbally when an individual contacts the hospital requesting an appointment,
and in any documents that are sent to the individual prior to the appointment.
d. The hospital employee responsible for getting signatures on discharge papers should be
required to remind the patient and/or their family that the hospital has a financial
assistance program, and application papers should be provided in the discharge packet.
e. Post-relevant information at local community organizations and/or faith based
organizations and the township trustee.
f. Prominently posted on the hospital website
g. Include information on the types of discounts that are available and detailed
information on eligibility guidelines.
h. Posted notices should be large in size and use terms and words that are easy for all to
understand.
2. Areas that have information posted on community benefit programs should also contain
applications for all relevant government insurance programs such as Medicaid, Medicare,
Healthy Indiana Plan and Hoosier Healthwise with assistance provided in filing for benefits
as needed.
3. Information posted should be available in alternate languages as well as alternate formats for
individuals with disabilities.
4. Staff working in areas such as hospital clinics, billing departments, emergency rooms and
other relevant areas should be provided adequate information on the types of charity care and
community benefits available at the hospital. These individuals should be able to explain the
programs and services to anyone when asked and be able to answer questions or direct the
patient to someone who can provide an accurate answer within a short period of time.
5. Detailed information and all applications should be available via the hospital’s website.
Billing/Payment Plans for Community Benefits – All billing must be clear, concise and easy
to understand.
1. Upon discharge from care, the patient must be reminded that the hospital has a financial
assistance program that may be able to help with payment of bills.
2. Any and all bills sent to a patient must include information on available payment plans as
well as other assistance that may help with the payment of outstanding debt.
3. If there is no response following multiple written correspondences, protocol should be
established for attempting to contact the individual in person or by phone prior to sending
unpaid bills to a debt collection service.
4. Payment plans MUST be designed with cooperation between the hospital and the patient.
Payments must be reasonable based on the individual income and expenses and not based on
a rigid pre-determined income scale.

29
5. Individuals who have trouble paying for care should be provided applications to appropriate
health insurance such as Medicaid, Medicare, HIP and Hoosier Healthwise. As appropriate
these individuals should also be provided assistance in completing these application forms.
6. Establishing partnerships with local community and faith based organizations to help with
providing education and information on payment plans and community benefits.
Additional items to consider:
1. At all “Health Fairs” and other community outreach events information should be available
in the form of brochures or other written materials that inform attendees of financial
assistance that is available from the hospital.
2. All staff who may answer the phone – whether in billing or general operators – must have
information on who to contact when individuals call asking for financial assistance and/or
community benefits and should have basic information on the type of financial assistance
that may be available.
3. Financial assistance counselors/appropriate staff must be available at all times in the
emergency room to provide information on financial assistance and to answer questions.

30
Appendix II
Financial Assistance Policies

31

FINANCIAL ASSISTANCE POLICY
I. PURPOSE

As part of its mission to improve the health of its patients and community through innovation and excellence
in care, education, research and service, Indiana University Health (“IU Health”) values charity, equality and
justice in healthcare. Indiana University Health is committed to serving the healthcare needs of all of its
patients, regardless of their ability to pay for such services. To assist in meeting those needs, Indiana
University Health has established this Financial Assistance Policy to provide financial relief to eligible
patients receiving Emergency or Medically‐Necessary Services. This policy was developed and is utilized to
determine patients’ financial ability to pay for services.

II. SCOPE

This policy applies to charges for all hospital and emergency services provided by Indiana University Health
Facilities (as defined below) and physician services processed by Indiana University Health Revenue Cycle
Services.

III. EXCEPTIONS

Any exceptions to this policy must be approved in writing by the Financial Assistance Committee.

IV. DEFINITIONS
a. Adjustments for Uninsured Patients Policy – a policy that provides a reduction in charges billed for any
patient/guarantor who at the time services are provided, has no insurance coverage for, or right to,
Indiana University
Health
Policy #: 88
Title: Financial Assistance
Policy
Department: Revenue Cycle
Services
Category: Policies
Section: Revenue Cycle Policy
Owner: cbeals
Effective Date:
Next Review: 12/16/2013

32
the payment of care, through employer‐based insurance, government‐sponsored coverage or third
party liability coverage.
Title: Financial Assistance Policy                               Policy #: 88                                            PAGE 2 of 6

b. Emergency Services – an emergency accident, meaning a sudden external
event resulting in bodily injury, or an emergency illness, meaning the sudden onset of acute
symptoms of such severity that the absence of immediate attention may result in serious
medical consequences.

c. Facilities‐– includes the following Indiana University Health hospitals and Indiana University
Health affiliated surgery centers. This includes: Methodist Hospital, Indiana University
Hospital, Riley Hospital for Children, Indiana University Health West, Indiana University
Health North, Indiana University Health Arnett, Indiana University Health Ball Memorial and
Indiana University Health Blackford Community Hospitals. The Indiana University Health
surgery centers are: Eagle Highlands Surgery Center, Beltway Surgery Center, Springmill
Surgical, Springmill Endoscopy, Indiana Endoscopy Center, Senate Street Surgery Center,
Ball Outpatient Surgery Center, ROC Surgery Center and all other locations identified by
Revenue Cycle Services.

d. Financial Assistance – a reduction in the amount of charges billed for patients who are
eligible for relief under this policy.

e. Financial Assistance Application – an application to receive Financial Assistance.

f. Financial Assistance Committee – a committee appointed by the Indiana University Health
Chief Financial Officer that meets routinely with the task of determining exceptions and
making account approvals under this Financial Assistance Policy and the Adjustment for
Uninsured Patients policy.

g. Financial Assistance Determination – a written decision indicating whether Financial
Assistance will be provided to a patient/guarantor.

h. Interest Free Payment Arrangements

• Consolidated Patient Statements: An invoice payment program that allows a patient up to
twenty (20) months to pay an outstanding balance without accruing interest. Exceptions
can be made at management discresion.

• Non Consolidated Patient Statements: An invoice payment program that allows a patient up
to twelve (12) months to pay an outstanding balance without accruing interest.
i. Limited Means‐an inability to pay full amounts due of the hospital/physician obligation and
qualifies for partial assistance. The patient/guarantor must request assistance and have
income between 200‐400% of poverty guidelines for insured patients to qualify for partial
assistance. For uninsured patients, limited means can extend beyond 400% and is based on a
sliding scale which incorporates income, number in the household and provides the
patient/guarantor relief beyond the 40% adjustment for uninsured patients.

j. MedicallyNecessary Services – inpatient or outpatient health care services
provided for the purpose of evaluation, diagnosis and/ or treatment of an injury,
illness, disease or its symptoms, which otherwise left untreated, would pose a
threat to the patient’s ongoing health status.

33

Services must:

• Be clinically appropriate and within generally accepted medical practice standards; and

• Represent the most appropriate and cost effective supply, device or service that can be safely
provided and readily available at a Indiana University Health hospital, with a primary purpose other
than patient or provider’s convenience.

V. POLICY STATEMENTS

i) General:
(a) Indiana University Health will not refuse, delay or discourage services based on a patient’s
ability to pay for the cost of such services.

(b) Indiana University Health will actively promote all patients’ awareness of the availability of
Financial Assistance. All patients will receive notification of Indiana University Health’s
Financial Assistance Policy and all uninsured patients will receive an application to
participate in the program.

(c) Indiana University Health will make reasonable attempts to confirm that a patient is not
eligible for Financial Assistance prior to assigning that patient’s account to an agency for
collection or otherwise engaging in extraordinary collection actions.

(d) Financial Assistance determinations will be made without regard to a patient’s age, sex, race,
creed, disability, sexual orientation, or national origin.

(e) When it is necessary to engage in such actions, Indiana University Health, and its contractors,
will engage in fair, respectful and transparent collections activities.

ii) Eligibility:
(a) Eligibility for Financial Assistance will be determined based upon a patient’s household
income and number of members in the household. A patient is eligible for Financial
Assistance, as described in Section V(ii), when the patient’s:
(1) Household income is equal to or less than 400% of the Federal Poverty Guidelines; or

(2) Household income is greater than 400% of the Federal Poverty Guidelines, the patient is
an uninsured patient, and qualifies based on an established sliding scale.

(b) Patients in the following categories are presumed to be eligible for Financial Assistance,
without a determination of household income:
(1) Patients whose financial need has been determined by the following third parties:
Wishard, Project Health, Children’s Special Health Care Services (CSHCS), Medicaid, Out‐
of‐State Medicaid;

(2) Patients who are pending Medicaid approval;

(3) Homeless patients; and

(4) Patients who have a hospital bill with a maximum balance to be determined by the
Executive Director of Revenue Cycle Services and who meet credit scoring and asset
determination criteria.

34

(c) Additional Requirements:
(1) For patients/guarantors who are otherwise eligible for Financial Assistance and whose
hospital and/or physician liability is greater than $ 60,000 Indiana University Health may
review available assets in determining eligibility and amount of Financial Assistance
provided. This dollar threshold may be

increased annually based on Indiana University Health price increases and at the
discretion of Revenue Cycle Leadership.

(2) Financial Assistance may be granted to patients/guarantors who qualify for government
programs when funding has been delayed. If later government assistance is approved, the
Financial Assistance awarded will be reversed. This includes but is not limited to when a
patient’s account is pending Medicaid approval.

(3) Financial Assistance may be granted to a deceased patient whose estate has been
determined to be without valuable assets.

(4) Financial Assistance will not be granted to non‐Consolidated Patient Statements patients
that have a physician bill with a balance less than $240.00.

(5) Indiana University Health will deny Financial Assistance for any patient/guarantor who
falsifies any portion of an application.

(6) All third party resources and non‐hospital financial aid programs, including public
assistance available through Medicaid, must be exhausted before Financial Assistance
will be awarded.

iii) Available Assistance
(a) When an insured or uninsured patient’s household income is less than or equal to 200% of
the Federal Poverty Guidelines or the patient meets one or more of the eligibility criteria
identified in Section V(ii)(b), Indiana University Health will provide one hundred percent
(100%) relief/financial assistance of allowable charges.

(b) When an insured or uninsured patient’s household income exceeds 200% of the Federal
Poverty Guidelines and is less than or equal to 400% of the Federal Poverty Guidelines,
Indiana University Health will provide a limited means adjustment/relief of allowable
charges based on household income and number in the family. This is calculated based on a
sliding scale. For insured patients, the limited means/partial assistance ends at 400%.

(c) When an uninsured patient’s household income exceeds 400% of the Federal Poverty
Guidelines, Indiana University Health will provide a limited means adjustment/partial
assistance of allowable charges based on household income and number in the family. This is
calculated based on a sliding scale. For uninsured patients, the limited means/partial
assistance ends when their ability to pay reaches the uninsured discount already granted by
Indiana University Health.

iv) Reporting:
(a) Indiana University Health will report on the amount of Financial Assistance provided to
eligible patients, and on any modifications to this policy, on an annual basis in its Community
Benefit Report.

VI. PROCEDURES
i) Communication:

35
(a) Indiana University Health will broadly communicate the availability of Financial
Assistance within the communities it serves by posting a description of this policy in
appropriate acute care settings such as emergency departments, registration areas,
and on its website.

• Signs will be posted in each of these areas describing the available assistance and
directing interested patients to the Financial Assistance Application.
• Brochures and other materials describing the program may be available in languages
other than English that are frequently spoken in the geographic vicinity of each
respective Indiana University Health hospital.

(b) Indiana University Health may include a description of this policy with all patient bills and
statements of services and will mail a Financial Assistance Application to each patient
eligible under the Adjustment for Uninsured Patients Policy upon the conclusion of
treatment, along with a summary of incurred charges.

(c) Indiana University Health Billing Services Center representatives will be available via
telephone Monday through Friday from 8 a.m. to 5 pm to assist with questions and
completion of financial assistance applications.

(d) Patients/guarantors may request a Financial Assistance Application using the Indiana
University Health web site or by calling the Billing Services Center.

(e) Each year, all Indiana University Health employees will be informed as to how to refer
patients to apply for the Indiana University Health Financial Assistance Program.

ii) Application:
(a) Patients/guarantors wishing to apply for Financial Assistance are responsible for initiating
the financial assistance process in a timely fashion and must return the Financial
Assistance Application to Indiana University Health Revenue Cycle Services within
twenty‐one (21) calendar days of receipt. Indiana University Health will consider
applications complete upon the submission of all requested documentation.

(b) Patients/guarantors must submit the following documentation with a completed application:
 Income from all sources.
 Copies of statements from savings and checking accounts, certificates of deposit,
stocks, bonds, money markets accounts, etc.
 Value of assets including home and real estate.
 Monthly expenses.
 Number of dependents.
 Copies of most recent three months of pay stubs.
 Copies of the most recent state and federal income tax forms including copies of:
 W2s
 Schedule C Profit or Loss from Business
 Schedule D Capital Gains and Losses
 Schedule E supplemental Income and Loss
 Schedule F Profit or Loss from Farming


• A signed copy of the Financial Assistance Application

• Any additional information requested by Indiana University Health to assist in the
verification of household income and assets.
(c) Individuals other than the patient, such as the patient’s physician, family
members, community or religious groups, social services, or hospital

36
personnel may request a Financial Assistance Application to be mailed to a
patient’s primary mailing address.

(d) The Financial Assistance Application and accompanying documentation must be
submitted annually. It is the patient’s responsibility to notify Indiana University
Health if the patient’s financial status has changed.

(e) Indiana University Health keeps all applications and supporting documentation
confidential.

(f) Once Financial Assistance has been granted, the patient/guarantor will not be supplied
with documentation required to bill insurance companies. This includes the UB,
1500 and/or detailed itemization bill forms.

iii) Determination:
(a) Indiana University Health will inform patients/guarantors of the results of their application by
providing the patient/guarantor with a Financial Assistance Determination within ninety
(90) days of receiving a completed application and all requested documentation.

(b) If a patient/guarantor is granted less than full assistance and the patient/guarantor
provides additional information for reconsideration, Revenue Cycle Services staff
may amend a prior Financial Assistance Determination.

(c) If a patient/guarantor seeks to appeal the Financial Assistance Determination further, a
written request may be submitted, along with the supporting documentation, to the
Financial Assistance Committee for additional review/reconsideration.

(d) Decisions of the Financial Assistance Committee are final.

iv) NonPayment/Collections:
(a) Patients/guarantors who have not applied for Financial Assistance and whose accounts have
been transferred to a collection agency may request Financial Assistance, complete an
application with requested documentation and be considered for reduction of their bill.
Indiana University Health may suspend collection activity on an account while an application
is being processed and considered. For a patient/guarantor who chooses not to participate
or is denied Financial Assistance, the full measure of collection activity will continue.

(b) Indiana University Health and its collection agencies will not provide assistance after an
account has entered legal proceedings without first obtaining written consent from

37
ADJUSTMENT FOR UNINSURED PATIENTS POLICY

I. PURPOSE

As part of our mission to improve the health of its patients and community through innovation and excellence
in care, education, research and service, Indiana University Health (“IU Health”) values charity, equality, and
justice in healthcare. As such, Indiana University Health is committed to serving the healthcare needs of all of
its patients, including Uninsured Patients, regardless of their ability to pay for such services. In order to
ensure transparency, consistency and fairness towards Uninsured Patients, this policy sets guidelines for
providing a financial adjustment to any Uninsured Patient who obtains Medically‐Necessary or Emergency
Services from Indiana University Health. This policy ensures Indiana University Health’s compliance with the
Patient Protection and Affordable Care Act, enacted March 23, 2010, Internal Revenue Code section 501 ( r ).
This requires tax‐exempt hospitals to limit amounts charged to uninsured patients for emergency and other
medically necessary care to no more than those amounts generally charged to insured patients.

II. SCOPE

This policy applies to charges for uninsured patients and includes scheduled, unscheduled, and Emergency
Services defined as Medically‐Necessary provided by Indiana University Health Facilities, as defined below.
Cosmetic and non‐Medically‐Necessary elective procedures are excluded.

III. EXCEPTIONS

Any exceptions to this policy must be approved in writing by the Financial Assistance Committee. No
exception will be made that would permit Indiana University Health to bill an Uninsured Patient for gross
charges incurred in connection with Medically‐Necessary or Emergency Services.

Policy #: 87
Title: Adjustment for
Uninsured
Patients Policy
Department: Revenue Cycle
Services
Category: Policies
Section: Revenue Cycle Policy
Owner: cbeals
Effective Date:
Next Review: 12/16/2013
Indiana University
Health

38
Title: Adjustment for Uninsured Patients Policy                       Policy #: 87                          PAGE 2 of 3

IV. DEFINITIONS
a. Emergency Services – an emergency accident, meaning a sudden external event resulting in
bodily injury, or an emergency illness, meaning the sudden onset of acute symptoms of such
severity that the absence of immediate attention may result in serious medical
consequences.

b. Facility – includes the following Indiana University Health hospitals and Indiana University
Health affiliated surgery centers. This includes: Methodist Hospital, Indiana University
Hospital, Riley Hospital for Children, Indiana University Health West, Indiana University
Health North, Indiana University Health Arnett, Indiana University Health Ball Memorial and
Indiana University Health Blackford Community Hospitals. The Indiana University Health
surgery centers are: Eagle Highlands Surgery Center, Beltway Surgery Center, Springmill
Surgical, Springmill Endoscopy, Indiana Endoscopy Center, Senate Street Surgery Center,
Ball Outpatient Surgery Center, ROC Surgery Center and all other locations identified by

c. Financial Assistance Committee – a committee appointed by the Indiana University Health
Chief Financial Officer that meets routinely with the task of determining exceptions, and
making account approvals under the Financial Assistance Policy and this Adjustment for
Uninsured Patients policy.

d. Financial Assistance Policy – policy in accordance with which Indiana University Health
provides financial relief to eligible patients.

e. MedicallyNecessary Services ‐ inpatient or outpatient health care services provided for the
purpose of evaluation, diagnosis and/or treatment of an injury, illness, disease or its
symptoms, which otherwise left untreated, would pose a threat to the patient’s ongoing
health status.

Services must:

• Be clinically appropriate and within generally accepted medical practice standards; and

• Represent the most appropriate and cost effective supply, device or service that can be safely
provided and readily available at a Indiana University Health facility, with a primary purpose
other than patient or provider’s convenience.
f. Uninsured Adjustment – the reduction in usual and customary charges billed for
Medically‐Necessary or Emergency Services provided to Uninsured Patients.

g. Uninsured Patient – a Indiana University Health patient who at the time services are
provided, has no insurance coverage for, or right to, the payment of care, whether through
employer‐based insurance, government sponsored coverage or third‐party liability
coverage.

V. POLICY STATEMENTS

a. Indiana University Health will not refuse, delay or discourage the provision of Medically‐
Necessary or Emergency Services based on a patient’s ability to pay for the cost of such
services.

39

Title: Adjustment for Uninsured Patients Policy                      Policy #: 87                           PAGE 3 of 3

b. Indiana University Health assists Uninsured Patients by providing an Uninsured Adjustment
based on the average rate of the three best negotiated Managed Care rates as calculated on
an annual basis.

c. The Uninsured Adjustment applies to charges for Medically‐Necessary hospital and emergency
room services provided to Uninsured Patients by Indiana University Health. The adjusted
amount for 2011 will be 40% of gross charges.

d. Indiana University Health will actively promote patients’ awareness of the availability of an
Uninsured Adjustment.

e. If paying the remaining balance of the Indiana University Health medical bill creates a financial
hardship, Uninsured Patients will be referred to the Financial Assistance Policy.

f. Provision of or eligibility for the Uninsured Adjustment has no bearing or impact on a patient’s
ability to apply or qualify for assistance under the Financial Assistance Policy.

VI. PROCEDURES
A. Indiana University Health will identify Uninsured Patients during registration and/or admissions
processes.

B. Indiana University Health Revenue Cycle Services department will automatically apply the
Uninsured Adjustment to facility account balances at the time of billing. This adjustment will
reduce the Uninsured Patient’s balance and shall be visible on the initial statement issued for
the services.

C. If, at any time, Indiana University Health Revenue Cycle Services becomes aware that a previously
identified Uninsured Patient was, in fact, covered by billable insurance at the time of service,
it will revoke the Uninsured adjustment and issue a revised statement to the patient.

D. Indiana University Health will clearly and completely describe the availability of the Uninsured
Adjustment on its website, in admission packets, with patient bills, and during other relevant
points of contact, including when asked about such a discount by an Uninsured Patient.

40
COMMUNITY HEALTH NETWORK   NET.FINANCE 003
NETWORK FINANCIAL POLICY Page 1 of 36

REVIEW/REVISION
DATE ACTION
12/13/05 Revised Section 4.1
06/16/06 Delete Section 1.11.5
11/01/06 Addition Section 3.9-3.12
01/15/07 Addition Section 6
03/29/07 Delete Attachment C and Section 1.11.3
01/29/08 Update Poverty Guidelines
02/12/08 Addition Section 3.3
02/02/09 Update Poverty Guidelines and 1.16.1
TITLE: FINANCIAL ASSISTANCE POLICY

EFFECTIVE DATE:    04/01/06

REPLACES: ADM B – 004
ADM B – 004A

TO BE READ WITH:  Net.Finance – 001:  Definitions

PURPOSE:  To document the specific, Community Health Network, Financial Assistance
Policy.  To ensure policy and procedures exist for identifying those patients for whom
service is to be rendered free of charge, or at a discount, based solely on ability to pay,
financial condition and availability of third party funding.  To clearly differentiate those
patients eligible for Financial Assistance, based on established guidelines, from those
patients with financial resources who are unwilling to pay.

PHILOSOPHY:  Community Health Network, in keeping with its mission, serves the
medical needs of the community, regardless of race, creed, color, sex, national origin, sexual
orientation, handicap, residence, age, ability to pay, or any other classification or
characteristic.  We recognize the need to render care to the sick who do not possess the
ability to pay.  Medically Necessary health care services will be provided to these patients
with no expected reimbursement, or at a reduced level of reimbursement, based upon
established criteria, recognizing the need to maintain the dignity of the patient and family
during the Process.  We expect all Responsible Parties with the ability to pay, to meet their
financial obligations in a timely and efficient manner, in accordance with our collection
policies.  The amount of free or discounted care considered will be reviewed and approved
without jeopardizing our continued financial viability.

POLICY STATEMENT:

1. POLICY:

41
1.1 Provision of Financial Assistance.

Annually, we will establish, a percentage of total consolidated operating expenses
for Financial Assistance as a component of the larger category of Community
Benefits. Further, we will monitor our ratio of Community Benefit cost to total
consolidated operating expense and benchmark against pre-determined
components of the applicable market with a goal of providing Community
Benefits in total at a ratio better than average within the applicable market served.
1.2 Non-discrimination.
We will render services to our patients who are in need of Medically Necessary
Services regardless of the ability of the Responsible Party to pay for such
services. The determination of full or partial Financial Assistance will be based
on the ability to pay and financial condition and will not be based on race, creed,
color, sex, national origin, sexual orientation, handicap, residence, age, or any
other classification or characteristic.
1.3 Available Services.
All available Medically Necessary health care services, inpatient and outpatient,
will be available to all individuals under this Policy.
1.4 Determination of Eligibility.
The determination of eligibility for Financial Assistance should be made before
providing services. If complete information on the patient’s insurance or the
Responsible Party’s financial situation is unavailable prior to rendering services
or at the time of services, or if the Responsible Party’s financial condition
changes, or if the patient requires Emergency Services, the determination of
eligibility will be made after rendering services. All efforts will be made to
establish eligibility for Financial Assistance before the patient leaves the
facility/first patient visit concludes.
Notwithstanding the foregoing, in keeping with the Emergency Medical
Treatment and Labor Act (EMTALA), as amended from time to time, no
determination of eligibility will be attempted until after an appropriate medical
screening examination and necessary stabilizing treatment have been provided.
1.5 Confidentiality:
The need for Financial Assistance may be a sensitive and deeply personal issue
for the patient/family. Confidentiality of information and preservation of
individual dignity will be maintained for all who seek Financial Assistance.
Orientation and training of staff and the selection of personnel who will
implement this Policy and procedure will be guided by these values. No

42
information obtained in the Financial Assistance application may be released
unless the patient/Responsible Party gives express written permission for such
release.
1.6 Staff Information:
All employees in patient registration, Billing, collections, patient accounting,
finance and Emergency Services areas will be fully versed in the Financial
Assistance Policy, have access to the application forms, and be able to direct
questions to the appropriate staff member(s).
1.7 Staff Training:
All staff with public and patient contact will be trained to understand the basic
information related to the Financial Assistance Policy and will provide
Responsible Parties with printed material explaining the Financial Assistance
program.
1.8 Financial Assistance Representative:
Each corporation will designate an individual to approve Financial Assistance
applications, coordinate outreach efforts and oversee Financial Assistance
practices.
1.9 Financial Assistance Appeals Committee:
Each corporation will establish a Financial Assistance Appeals Committee or
process that provides for at least three (3) members, excluding the Financial
Assistance Representative, to review appeals from those whose applications have
been denied or which do not provide for a level of Financial Assistance to which
the Responsible Party believes he/she is eligible.
1.10 Physician Participation:
We will encourage and support physicians with admitting privileges and others
who provide services to our patients to establish and implement Financial
Assistance programs for the patients they see in connection with services rendered
by us.
1.11 Notification:
1.11.1 Posters and Brochures:
A notice (Attachment A) of the availability of Financial Assistance will be
posted in each patient registration and waiting area. Brochures
(Attachment B) explaining the Financial Assistance program will be

43
placed in each patient registration and waiting area. In the case of services
rendered in the home, the brochure will be provided to the Responsible
Party during the first in-home visit. All publications and informational
materials related to the Financial Assistance program will be translated
into languages appropriate to the population in the service area.
1.11.2 Oral Notification:
Every Responsible Party will be told that we have a Financial Assistance
program in the appropriate language during any pre-admission,
registration, admission or discharge Process.
1.11.3 The front of each Past Due Notice (first, second and third) will
substantially meet the contents and language in Attachments C through E.
1.11.4 “About Your Bill: Frequently Asked Questions.” One is for those with a
Third Party Payer and one is for those without a Third Party Payer.
Copies of these documents will be available in patient registration areas
and through the Business Offices and Patient Financial Counselors. These
documents will substantially meet the content and language set forth in
Attachment F.
1.11.5 We will make available a notice titled “Registering For Services: What
You Need To Know”. This notice will be available in patient
registration areas and through the Business Offices and Patient
Financial Counselors. This document will substantially meet the content
and language set forth in Attachment G.
1.12 Uniformity:
This Policy applies to all Community Health Network corporations that provide
health care items and services to patients as adopted by the applicable Boards of
Directors.
1.13 Reporting:
Reporting of Financial Assistance shall be in accordance with all applicable laws,
rules and regulations including Indiana Code 16-21-9-7, as amended and
recodified from time to time. Such report will be made available to the public
upon request.
1.14 Corporate Responsibility:
Each corporation’s principal executive officer or officers and the principal
financial officer or officers, or persons performing similar functions, will certify
in each annual report, that the signing officer has reviewed the report and based

44
on the officer’s knowledge, the report does not contain any untrue statements of a
material fact or omits to state a material fact.
1.15 Accounting:
Accounting for Financial Assistance will be in accordance with the Community
Benefits Accounting Policy.
1.16 Internal Record Keeping:
1.16.1 Application for Financial Assistance:
The completed applications will be kept on file for at least five (5) years.
A copy of the application and all correspondence regarding the
application, approval, denial and/or appeal will be maintained in the
patient’s financial file.
All debt discharged shall be recorded in a manner in keeping with the
resources available to each corporation/business unit and in a manner that
permits access to such information for record keeping, reporting and
analysis purposes.

1.16.2 Automatic Discounts for the Uninsured:

All automatic discounts for the Uninsured will be coded specifically as an
“automatic discount for the Uninsured” in a manner in keeping with the
resources available to each corporation/business unit and in a manner that
permits access to such information for record keeping, reporting and
analysis purposes.
1.16.3 Prohibition on Medical Record Documentation:
No records will be placed in or notations made in a patient’s health
(medical) record regarding financial matters, including whether the patient
paid all or part of any medical Bill.
2. UNINSURED PATIENTS: CRITERIA TO BE ELIGIBLE FOR DISCOUNTS
AND DISCOUNT AMOUNTS:
2.1 Patients who are Uninsured are automatically eligible for a discount from gross
Charges. Such discount shall be applied to the patient’s Bill as early in the Billing
Process as possible. The Responsible Party will be provided with a notice that
such discount has been applied which will be sent with the Statement. (See
Attachment F, “About Your Bill: Frequently Asked Questions for Self-pay
Patients”)

45
2.2 Discounts from gross Charges for the Uninsured shall be as follows:
2.2.1 Gallahue Mental Health Center: In accordance with the Center’s sliding
scale discount policy as a grant funded business unit.
2.2.2 Community Family Practice: In accordance with the Practice’s
sliding scale discounts as a service partially funded by the Indiana Health
Coverage Program (Medicaid) and Medicare.
2.2.3 Community Physicians of Indiana: Twenty percent (20%)
2.2.4 Hospitals: Thirty percent (30%), except/and as follows.
2.2.4.1 Infertility/Related Services: Zero percent (0%) (1)
2.2.4.2 Cosmetic Surgery/Related Services: Zero percent (0%) (1)
2.2.4.3 Bariatric Surgery/Related Services: Zero percent (0%) (1)
2.2.4.4 MedCheck Services: Twenty percent (20%) with payment at
time of service.
2.2.4.5 Maternity Care Center: Thirty percent (30%)
2.2.4.6 Hook Rehabilitation Center: Thirty percent (30%)
2.2.4.7 SNF Units: Thirty percent (30%)
2.2.4.8 Community Health Network Employees Eligible for Discounts:
in accordance with our Human Resources policies.
2.2.4.9 Physicians’ Billing Service For Amounts Owned by Network:
Twenty-percent (20%)
2.2.4.10 Community Business Innovations: Zero percent (0%)
2.2.4.11 Community Home Health Services: Thirty percent (30%)
2.2.4.12 Community Long Term Care: Zero percent (0%) (2)
(1) This policy (2.2) does not apply to these services because these
services are packaged priced which already includes a discount.
(2) This policy (2.2) does not apply to Community Long Term Care
because it has its own Board adopted policy regarding patients without
insurance.

46
2.3 When an Uninsured patient has been given a discount on an account(s) under this
policy and the patient subsequently qualifies for free care for those accounts, total
charges will be applied to the traditional charity care component of Community
Benefit.
2.4 If we have extended a discount to the Uninsured patient and subsequently
determine that third party funding is available, the discount may be reversed and
the funding source Billed at full Billed Charges.
2.5 While this policy provides for discounts from Charges for services that are
excluded services under a patient’s benefit plan and for Charges for services that
are above the benefit limits of the patient’s benefit plan, we have no obligation to
extend such discounts unless we know in advance of the provision of services or
the Responsible Party contacts us following the provision of services regarding
payment for those services.
3. CRITERIA FOR ELIGIBILITY FOR FREE CARE:
3.1 In order to be eligible for free care or discharge of debt under this Policy the
patient must be a U.S. citizen or a legally residing non-citizen.
3.2 Requests for consideration of discharge of debt may be proposed by sources other
than the Responsible Party, such as the patient’s physician(s), family members,
community or religious groups, social services organizations, or Network
personnel. We will inform the Responsible Party of such a request and it will be
processed as any other such request.
3.2 The Responsible Party must complete an application (Attachment H), provide all
requested information in a timely manner, fully participate in and cooperate with
the Process and meet the eligibility requirements.
3.3 In an effort to screen 100% of patients for potential charity care eligibility,
Community Hospital East, Community Hospital North, Community Hospital
South and The Indiana Heart Hospital utilizes data from trusted third-party
vendors to automatically estimate the financial condition of each patient. This
data is collected from multiple sources using multiple methodologies including
predictive modeling to maximize the accuracy of these financial estimates. To
accomplish these tasks, the aforementioned hospitals use technology from
MedeAnalytics; a leading provider of analytics software, based in Emeryville,
CA. The MedeAnalytics platform enables the Community Health Network to
automatically gather financial and demographic information for each patient from
third-party data vendors including Acxiom Corporation and Equifax, Inc. Each of
these vendors provides an estimation of household size and income required to
calculate federal poverty level.

47
Acxiom Corporation aggregates census information, public records and self
reported information to estimate the financial conditions of consumer households.
Equifax, Inc. uses a different methodology based on available credit balances and
monthly credit obligations to estimate income and household size. Each of these
data vendors use sophisticated predictive modeling techniques to increase the
accuracy of these estimates based on millions of historical records.
On a daily basis, all accounts with balances due from the patient (Inpatient and
Outpatient) are checked against these third-party databases automatically, and
segmented based on Federal Poverty Level and the specific guidelines of the
Community Health Network financial assistance program. This approach is
consistently applied, leveraging automated analytics technology, in an unbiased
fashion to all accounts.
Patients who are very likely to qualify for financial assistance, based on third-
party Federal Poverty Level estimates, receive a charity care adjustment
according to Community Health Network charity care guidelines. Patients at
higher Federal Poverty Level thresholds have the opportunity to complete a
financial assistance application and meet with a financial counselor to determine
payment and assistance options. This approach enables the Community Health
Network to efficiently serve the community while using a consistent approach to
identifying all patients with a need for financial assistance.
3.4 A Responsible Party’s debt under this Policy includes gross or discounted
Charges, and Charges for services not covered by a third party payer including
deductible, co-payment and co-insurance amounts, and amounts for non-covered
services including amounts for services beyond the benefit limits of the third party
coverage.
3.5 For discharge of one-hundred percent (100%) of debt, the Responsible Party has a
family income level at or less than two-hundred percent (200%) of the Federal
Poverty Guidelines, as adjusted by the Federal Government from time to time,
and no other financial resources from which to make payment. As of January 23,
2009, two-hundred percent (200%) of the Federal Poverty Guidelines is as
follows.
Family Size Monthly Income Annual Income

1 $1,805 $21,660
2 2,428 29,140
3 3,052 36,620
4 3,675 44,100
5 4,298 51,580
6 4,922 59,060
7 5,545 66,540
8 6,168 74,020

48

For each additional person, add $7,480 annually.
3.6 Determining financial eligibility. We will determine eligibility using the Official
Measure of Poverty published by the Census Bureau as adjusted from time to
time.
3.6.1 Family Size is as follows:
3.6.1.1 When the patient is a non-emancipated minor: biological mother
and father and/or step parent(s) if child is adopted and all persons
on the tax return(s), filer(s) and dependents of same; or, in the
event that that another person not listed herein signed for financial
responsibility, the person who signed plus the spouse and all
dependents on that person(s) tax return(s).
3.6.1.2 When the patient is not a minor or is an emancipated minor: the
patient, the spouse and the dependents of same on the tax return(s)
of the patient and/or spouse; or, in the event that another person
not listed herein signed for financial responsibility, the person who
signed plus the spouse and all dependents on that person(s) tax
return(s).
3.6.2 Family Income is that of those listed in Section 3.6.1 above as applicable.
3.6.3 Income includes total annual cash receipts before taxes from the following
sources. Money income including 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, including that of the Responsible Party not
residing with the patient, and other miscellaneous sources.
3.6.4 Income does not include the following: Non-cash benefits (such as food
stamps and housing subsidies), and capital gains or losses.
3.6.5 Living expenses are not subtracted to determine income.
3.7 We will assume that a Responsible Party who has filed bankruptcy and whose
debts to us have been fully or partially discharged by the Court have met the
criteria necessary for us to write-off the discharged debt to Charity Care.
3.8 We will assume that a deceased patient with no estate and with no other
Responsible Party for payment has met the criteria necessary for us to write-off
the discharged debt to Charity Care.

49
3.9 We will assume a homeless patient, with no evidence of assets through
communication with the patient, credit reports and other appropriate means and
with, to the best of our knowledge, no Responsible Party, financial assistance
from a Government Benefit Plan or Government Sponsored Health Care for the
Indigent for payment, has met the criteria necessary to write-off discharged debt
to Charity Care.
3.10 We will assume a patient whom we know to be an illegal alien, with no evidence
of assets through communication with the patient, credit reports and any other
appropriate means, who refuses to cooperate with us in applying for governmental
payment and/or with, to the best of our knowledge, no Responsible Party,
financial assistance from a Government Benefit Plan or Government Sponsored
Health Care for the Indigent for payment, has met the criteria necessary to write-
off discharged debt to Charity Care.
3.11 With the exception of accounts already submitted to a collection agency, current
debt on accounts not yet submitted to a collection agency and debt incurred on
and between the initial date of application and the date of approval and within
ninety (90) days following the date of approval will be subject to the terms of the
approval or denial.
With respect to accounts already submitted to a collection agency: If the
collection agency has not yet incurred attorney fees and/or court costs, the charges
will be written-off to Charity Care. If the collection agency has incurred attorney
fees and/or court costs and the application has been approved, the amount payable
by the Responsible Party for health care services will be written-off to Charity
Care. The Responsible Party will remain financially responsible for payment of
the attorney fees and/or court costs.
3.12 When a Medicaid patient is admitted for in or outpatient services and has unpaid
accounts for dates of service within ninety (90) days prior to the patient’s
Medicaid effective date; and to the best of our knowledge, there is no Responsible
Party, financial assistance from a Government Benefit Plan or Government
Sponsored Health Care for the Indigent for payment, we will assume the patient
has met the criteria necessary to write-off the discharged debt to Charity Care.
3.13 If a patient has made a payment(s) on his/her account(s) and subsequently
qualifies for free care for those account(s), we are not obligated to refund the
payments made because the patient demonstrated the ability to make payment as
evidenced by the payment having been made.
4. OTHER DISCHARGE OF DEBT
4.1 Responsible Parties who do not qualify for Financial Assistance under 3 above,
and have medical/dental debt equal to or greater than twenty-five percent (25%)

50
of annual income, as set forth on the Financial Assistance Application and
determined through the Financial Assistance Application process, may be given a
discount based on the totality of their circumstances. The amount of the discount
will be at the discretion of the Financial Assistance Representative.
4.2 Responsible Parties who do not qualify for Financial Assistance under 3 and 4.1
above and whose debt to us exceeds their ability to pay, we may discount the
Charges. The determination of ability to pay and the amount of the discount will
be at the discretion of the Financial Assistance Representative.
Note: Sections 3.0 and 4.0 above are not applicable to Community Home Health
Services and Community Long Term Care because they have their own Board
adopted policies.
5. OTHER FINANCIAL ASSISTANCE
At the discretion of the Financial Assistance Representative we may pay health insurance
premiums, including COBRA premiums, to assist the patient in maintaining health
insurance coverage so long as the patient is receiving services from us which are covered
services under the patient’s benefit plan.
6. SPECIFIC BUSINESS UNIT EXCEPTIONS:

Notwithstanding the foregoing, certain Business Units within the Network are
exempted from the provisions of Sections 3, 4 and 5 herein above due to the
unique nature of that Business Unit. Set forth below are the Business Units and
their specific financial assistance policy.

6.1 MedChecks: MedCheck accounts subject to Financial Assistance shall be
limited to those for services rendered by MedCheck which are reasonably
related to the hospital services for which Financial Assistance has been
granted.

7. APPLICATION AND APPEALS PROCESS
7.1 APPLICATION PROCESS
7.1.1 An application and financial statement for Financial Assistance will be
provided to any requesting party. This may be done in person or by mail.
(Attachments H and I)
7.1.2 Assistance in completing the application will be offered and provided to
the Responsible Party.
7.1.3 The Responsible Party (“applicant”) will have fifteen (15) calendar days
following the Initial Date of Request on the application to complete and

51
return the application. The applicant may request an extension of fifteen
(15) calendar days for good cause and such extension shall not be
unreasonably denied. Failure to return a complete application within said
fifteen (15) days or, if extended, thirty (30) days will result in denial of the
application and no discharge of debt.
7.1.4 Upon receipt of a complete application, it will be approved or denied
within thirty (30) business days following the date of receipt and the
applicant, and the physician if appropriate, will be notified, by telephone,
certified mail or regular mail with an assumption of receipt five (5) days
following the date mailed, of the result, including the amount of debt to be
discharged and, if any, the amount of the remaining debt and due date, no
later than the next business day.
7.1.5 With the exception of accounts already submitted to a collection agency,
current debt on accounts not yet submitted to a collection agency and debt
incurred on and between the initial date of application and the date of
approval and within ninety (90) days following the date of approval will
be subject to the terms of the approval or denial.
With respect to accounts already submitted to a collection agency: If the
collection agency has not yet incurred attorney fees and/or court costs, the
charges will be written-off to Charity Care. If the collection agency has
incurred attorney fees and/or court costs and the application has been
approved, the amount payable by the Responsible Party for health care
services will be written-off to Charity Care. The Responsible Party will
remain financially responsible for payment of the attorney fees and/or
court costs.
7.1.6 The applicant will be given or mailed a copy of the application or a letter
indicating approval or denial and, if approved, the amount of debt
discharged, any balance due and the date due.
7.1.7 The applicable accounts will be adjusted.
8. APPEALS PROCESS
8.1 If the application is denied or the amount of debt to be discharged is
unsatisfactory, or financial conditions have changed, the applicant may appeal the
decision.
8.2 The appeal must be in writing and include the basis for the appeal.
8.3 The appeal must be received within fifteen (15) business days following the date
the applicant received the decision. For purposes of this process, submission of
additional information does not require review by the appeals committee.

52
8.4 The appeals committee will convene and make a decision within fifteen (15)
business days following receipt of the appeal.
8.5 No later than five (5) business days later, the applicant, and physician if
appropriate, will be notified of the results by telephone and by certified mail or
regular mail with an assumption of receipt five (5) days following the date mailed.
If the debt to be discharged has changed, the notice will include the total debt to
be discharged and, if any, the balance due and date due.
8.6 The decision of the appeals committee will be final but does not preclude the
filing of a new application for debt not subject to the application that was under
consideration.
Formulated By: Jacquelyn D. Johnson
Team Leader, Managed Care and Legal Projects
Approved By: ____________________________________________
Thomas P. Fischer, CFO
Date: _________________

58
SISTERS OF ST. FRANCIS HEALTH SERVICES, INC.
MISHAWAKA, INDIANA
Number: 300.04
Original Date: 02/10/05
SUBJECT: Charity Care And Uninsured Patient Discount Policy
PREFACE: Through the Sisters of St. Francis Health Services, Inc. (SSFHS), we
continue the healing ministry of Christ in a Catholic healthcare system that upholds the
moral values and teachings of the Catholic Church. Central concerns of this corporate
ministry include compassion for those in need and respect for life and the dignity of
persons.
We believe in the dignity, uniqueness, and worth of each individual and, within the limits of
our resources, we offer a comprehensive range of healthcare services to all regardless of
race, creed, color, sex, national origin or handicap. In light of this belief, we consider our
healthcare services to be reaching out and responding, in a Christ-like manner, to those who
are physically, materially, or spiritually in need.
DEFINITIONS
Charity - The action of reaching out and responding, in a Christ-like manner, to those who
are physically, materially, or spiritually in need.
Charity Care - The cost of healthcare services, provided in accordance with the Charity
Care and Uninsured Patient Discount Policy, for which no or partial reimbursement will be
received because of the recipient’s inability to pay for those services.
Guarantor - The person who is financially responsible for payment of services provided by
the facility.
Patient - The person who is the recipient of services provided by the facility.
Prompt Pay Discount - If applicable, a discount on the patient balance owed if paid in full
and within a specified timeframe as may be established by SSFHS' facilities, if applicable.
Uninsured - Patients who do not have any insurance and are not eligible for federal, state, or
local health insurance programs.
CORPORATE POLICY

59
Unininsured Patient Discount or Discount - A discount provided to patients receiving
medically necessary health care services who do not have any insurance and are not
eligible for federal, state, or local health insurance programs.
POLICY: This policy is intended to address the financial assistance needs of patients:
A. Through the provision of Charity Care:
1. To patients whose level of income falls within or below a predetermined range
of income (based upon a multiple of the U.S. Federal Poverty Level Guidelines);
or
2. To patients who have limited financial means relative to their medical bills and
are unable to pay, in part or in full, for medical services provided, without
incurring undue financial hardship.
B. Through the provision of financial discounts to uninsured patients who have the means
to pay for medical services provided.
This Policy is not intended to create any legal entitlement or to constitute a binding contract
or agreement for or on behalf of any person, nor is the policy intended to cover elective
cosmetic medical services or existing facility self-pay, flat-rate pricing arrangements.
STATEMENT OF PURPOSE
To best serve the community needs of each locality, this policy identifies the circumstances
under which the facilities comprising SSFHS will extend Charity Care to patients whose
financial status makes it impractical or impossible to pay for necessary medical services, and
the circumstances under which SSFHS facilities will provide discounts to uninsured patients
who have the means to pay for medical services provided. The necessity for medical
treatment of any patient will be based on sound clinical judgment without regard to the
financial status of the patient. SSFHS' Charity Care policy is designed primarily for those
patients, whether employed or not, who do not have adequate private insurance, who do not
qualify for Medicaid or other governmental or social service programs, and where no other
person or entity is obligated to pay.
This policy is a vital component of SSFHS' Social Accountability agenda by which we hold
ourselves accountable to our constituencies in those communities where we are privileged to
serve.
FINANCIAL ASSISTANCE
Charity Care
Charity Care may be available to patients incurring emergency, urgent or emergent elective
medical procedures and admissions. The level of Charity Care provided is based on U.S.

60
Federal Poverty Level Guidelines with a sliding adjustment scale starting from 200% and up
to 300% of the U.S. Poverty Level Guidelines. See the Charity Care and Uninsured Patient
Discount Procedures for eligibility and application provisions.
Uninsured Patient Discount
The minimum discount offered by SSFHS' facilities to eligible uninsured patients will be
20% of billed charges. Individual facilities may offer additional Discounts based on the
facts and circumstances unique to their local markets. Any facility special package pricing
in effect will not be impacted by this Policy. This Discount shall not be combined with
other facility discounts, except for any Prompt Pay Discount as may be established by
SSFHS' facilities. No Discount shall be provided that violates any laws or government
regulations. See the Charity Care and Uninsured Patient Discount Procedures for eligibility
and application provisions.
PROCEDURAL CONSIDERATIONS
Internal facility procedures for determining patient eligibility for Charity Care or Uninsured
Patient Discounts will necessarily change over time and the then current facility procedures
are to be referenced as appropriate.
COMMUNICATION
Each SSFHS facility shall post a notice regarding the availability of financial assistance for the payment of medical services provided
to patients. Notices shall be posted in a visible manner in locations where there is a high volume of inpatient or outpatient
admitting/registration such as the emergency departments, billing offices, admitting offices, and outpatient service settings.
Posted notices shall contain the following:
A. A statement indicating that the facility has a financial assistance policy for patients
who may not be able to pay their bill and that this policy provides for Charity Care and
Discounts for medically necessary health care services; and
B. A contact phone number that a patient can call to obtain more information about the
Charity Care and Uninsured Patient Discount Policy and about how to apply for such
assistance or Discounts.
Oral and written communication to patients regarding the availability of and application
process for financial assistance for the payment of medically necessary health care
services shall be done in the primary language(s) of its service area and in a manner
consistent with all applicable federal and state laws and regulations. In particular, the
primary language(s) should be used on items such as: posted notices, the Financial
Assistance Application Form, and the Uninsured Patient Discount Form, which is
required to be filled out by the patient or the patient's guarantor, and the text of the
Charity Care and Uninsured Patient Discount Policy. In addition, the facility shall
provide, in the primary language(s), a written notice on the billing statement or via an

61
insert to the billing statement informing the patient that financial assistance may be
available either from a government program or under the facility's own Charity Care and
Uninsured Patient Discount Policy.
MONITORING & REPORTING
To facilitate timely monitoring and reporting of Charity Care, the patient accounting
department will use appropriately identified transaction codes when writing off Charity Care
allowances. Periodic reports will be prepared for management's use and discussions and
presentation to SSFHS' leadership committees.
Uninsured Patient Discounts will be classified in the facilities’ financial statements in the
Deductions from Revenue section in the account “Uninsured Patient Discounts”. The
cost of medical services classified as Uninsured Patient Discount will be included in
quarterly and annual Social Accountability and Community Benefit reports.
The patient accounting staff will review accounts which have been turned over to SSFHS'
collection agencies in an effort to identify and report any amounts which were originally
thought to be bad debts when, after further investigation, were found to be Charity Care
allowances. If such accounts are identified, the patient or the patient's guarantor may be
requested to provide some documentation for the Charity Care eligibility process. Under all
circumstances, accounts falling into this category will be handled in a manner that fosters
dignity and compassion for the patient.
DISCLAIMER
This document is intended to serve as a statement of policy and not as a contract or
agreement with any patient or former patient. This document does not entitle any person to
Charity Care or Uninsured Patient Discounts. This document does not create and is not
intended to create any third party beneficiaries nor is it intended to create any legal rights
with regard to any person or entity, including but not limited to any patient, former patient,
governmental entity or agency, third-party payor or guarantor or anyone acting on behalf of
such entity or administering benefits for such entity. This document does not create and is
not intended to create any legal duties with regard to SSFHS or its facilities to any person or
entity. All determinations of facility management or the Patient Financial Assistance
Committee are final and are committed to the sound, unfettered discretion of such personnel
or committee.
This policy replaces Corporate Charity Care Policy (300.03).
Secretary, Board of Trustees
Reviewed: 03/11/96
Reviewed: 02/23/99
Revised: 12/06/01

62
Revised: 02/10/05
Reviewed: 03/05/10
SISTERS OF ST. FRANCIS HEALTH SERVICES, INC.
MISHAWAKA, INDIANA
CORPORATE POLICY AND PROCEDURE
Number: CO 5070
Original Date: 07-15-2006
Latest Review/Revision: 04/05/2011
Subject: CBO Patient Financial Policy
Policy: It is the policy of Franciscan Alliance that necessary medical care will be rendered
to all patients regardless of their ability to pay. We will first try to secure reimbursement
coverage for the patient, but will then extend financial assistance for patients that can not
pay for their services.
Procedure:
A. The registration staff is responsible for verifying insurance benefits via the electronic
verification system. Patients that do not have insurance are also screened against the
Medicaid database to see if they may have neglected to inform us of Medicaid Coverage.
B. If a patient presents with insurance that requires prior authorization, this is then also
completed by the registration staff. Authorization approval is documented in the system.
C. If patient is not covered by insurance, the registrar first discusses possible payment
arrangements. If patient seems eligible, the bank loan information is discussed. If patient
may qualify for Medicaid, this is also discussed as an option. Patients that do not have the
funds to pay for their services and cannot be covered by a government program are then
offered financial assistance.
D. Financial Assistance can cover from 20% to 100% of the patient balance. The adjustment
is based on family income and available assets.
E. Financial Assistance is offered to every person needing medical care and cannot afford to
pay for the services. Patients that have insurance may also receive financial assistance for
their portion to pay after the insurance payment.

63
F. All inpatient self pay accounts and all outpatient self pay accounts over $2000 are
screened for possible coverage by State or Federal programs.
G. Patients that are making payments have the following options:
1. Cash, check, or money order
2. Visa, Master Card, Discover, American Express
3. Bank financing
4. Payment plans up to 12 months.
H. Charity information is posted at every registration site and the availability of charity is
also noted on every patient statement. Patients receive a total of 4 statements before any
account is referred to collection. The financial assistance application is also available on
the website.
I. Prior to Early Out placement, all self pay accounts are again screened against the
Medicaid data base to validate that Medicaid is still not available.
J. Patients can still apply for financial assistance once the account has gone to collection.
The agency will send the patient the financial assistance application and the same
approval review will take place.
ASSOCIATE (s)
RESPONSIBLE: ALL STAFF
Executive Director CBO
Vice President Revenue Cycle Management
Date

64
Appendix III
Financial Assistance Adjustment Tables in relation to
the Federal Poverty Guidelines

67
Franciscan Alliance, Inc.
(Sisters of St. Francis
Health Services)
2011 Charity/Financial Assistance Matrix
FPL x 2.2 FPL x 2.4 FPL x 2.6 FPL x 2.8 FPL x 3
Family Size 100% 80% 60% 40% 20%
1 $23,958 $26,136 $28,314 $30,492 $32,670
2 $32,362 $35,304 $38,246 $41,188 $44,130
3 $40,766 $44,472 $48,178 $51,884 $55,590
4 $49,170 $53,640 $58,110 $62,580 $67,050
5 $57,574 $62,808 $68,042 $73,276 $78,510
6 $65,978 $71,976 $77,974 $83,972 $89,970
7 $74,382 $81,144 $87,906 $94,668 $101,430
8 $82,786 $90,312 $97,838 $105,364 $112,890
Family Size 2011 Federal Poverty Guidelines
1 $10,890
2 $14,710
3 $18,530
4 $22,350
5 $26,170
6 $29,990
7 $33,810
8 $37,630
each additional person $3,820

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