Idea Transcript
Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Financial Assistance I.
Purpose This policy provides financial assistance guidelines for the provision of free or discounted, eligible Medically Necessary services to patients who meet certain eligibility criteria and demonstrate an inability to pay.
II.
Scope This policy applies to all patients who are residents of Louisiana or Mississippi and receive either Professional Services or Technical Services at Ochsner Health System (Ochsner), as listed on Attachment D, that are Medically Necessary and who meet certain eligibility criteria.
III.
Definitions A. Emergency Medical Conditions– Defined within the meaning of section 1867 of the Social Security Act. B. Expected Payments- All claims allowed by insurers. C. Family Income– Defined by the Census Bureau which includes earnings, unemployment compensation, worker’s compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources on a pre-tax basis. The following are excluded from calculation as Family Income by the Census Bureau: 1. Noncash benefits (such as food stamps and housing subsidies); 2. Capital gains or losses; and 3. Non-relatives, such as housemates. D. Federal Poverty Level (FPL)– The set minimum amount of gross income that a family needs for food, clothing, transportation, shelter and other necessities and varies by family size as set forth by the Department of Health and Human Services. E. Financial Assistance–refers to healthcare services provided by Ochsner without charge or at a discount to qualifying patients. F. Gross Charges– Total charges at the facility’s full established rates for the provision of patient care services before deductions from revenue are applied. G. Medically Necessary– Services that are reasonable or necessary for the diagnosis or treatment of an illness or injury. Medical Necessity will be determined by the examining physician.
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Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Financial Assistance H. Patient Portion- The amount the patient is financially responsible for after insurance has been applied to the bill for the services rendered. I.
Professional Services- services provided by a physician or clinical professional.
J.
Self Pay Discount– Discount applied to amounts due from patients for uninsured services.
K. Technical Services- medical or technical equipment, supplies or services. L. Underinsured– Patient has some form of third party assistance but still has out-ofpocket expenses that exceed his/her ability to pay. M. Uninsured– Patient has no form of third party assistance to assist with financial responsibility for medical services. IV.
Policy Statements A. Ochsner is committed to providing Financial Assistance for Medically Necessary Care to persons who are Uninsured, Underinsured, ineligible for a government program, or otherwise unable to pay, and who are determined to be eligible for Financial Assistance in accordance with this policy. Ochsner shall provide, without discrimination, care of Emergency Medical Conditions to individuals regardless of their eligibility for Financial Assistance or for government assistance. B. Patients who are determined eligible for Financial Assistance shall not be deferred for Medically Necessary care. C. Patients are expected to cooperate with Ochsner’s procedures for obtaining Financial Assistance or other forms of payment, and to contribute to the costs of their care based on their individual ability to pay. D. The granting of Financial Assistance shall be based on an individualized determination of financial need and will not take into account age, gender, race, social or immigration status, sexual orientation, or religious affiliation.
V.
Procedures/Standards and Roles & Responsibilities A. Eligibility for Financial Assistance 1. Financial Assistance applies to patient liability only, including but not limited to, deductibles, co-payments, and co-insurances and is available to residents of Louisiana and Mississippi. Eligibility for Financial Assistance is determined based on the patient’s Family Income, assets, and family size. 2. Ochsner shall provide a 100% Financial Assistance discount for eligible services to patients whose Family Income is at 200% of the FPL Guidelines or less.
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Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Financial Assistance 3. Patients whose Family Income exceeds 200% of the FPL may be eligible to receive discounted rates on a case-by-case basis based on their specific circumstances, such as catastrophic illness or medical indigence, at the discretion of Ochsner. For exceptions, documentation may be required to qualify for Financial Assistance. Exceptions include, but are not limited to: a. Expensive medications; b. Terminal illness; or c. Multiple hospitalizations. 4. Failure to comply with Ochsner’s Medicaid coverage and Financial Assistance screening process will exclude patients from Financial Assistance eligibility. 5. Modifications to previously awarded discounts shall be made if subsequent information indicates the information provided to Ochsner was inaccurate. B. Services Available Under this Policy 1. Financial Assistance is available for all Professional Services and Technical Services, except for the following: a. Pre paid, fixed price services; b. Transplant services; and c. Fees for Professional services rendered by the providers as listed on Attachment A. C. Methods by Which Patients May Apply for Financial Assistance 1. Financial Assistance requests can be made by contacting the Patient Account Customer Service department via telephone, email, fax, or written correspondence or by visiting the Patient Financial Services Department located at Ochsner Health System facilities. 2. Financial need will be determined by an individual assessment of financial need and may: a. Include an application process (“Attachment B”), in which the patient or the patient’s guarantor, is required to cooperate and supply personal, financial, and other information and documentation relevant to making a determination of financial need; i.
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The Financial Assistance application is required to provide additional information to allow for a more in-depth review of borderline approvals, hardship cases, and large balances.
Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Financial Assistance b. Include the use of external publicly available data sources that provide information on a patient’s or a patient’s guarantor’s ability to pay (such as credit scoring); c. Use a third party tool when there is insufficient information provided by the patient and may be utilized as the sole documentation source to make a Financial Assistance determination; d. Include reasonable efforts by Ochsner to explore appropriate alternative sources of payment and coverage from public and private payment programs and to assist patients to apply for such programs; or e. Include a review of the patient’s outstanding accounts receivable for prior services rendered and the patient’s payment history. 3. Applications for Financial Assistance are considered on an episode-of-care by episode-of-care basis. A patient has 240 days from the date of the first postdischarge bill for an episode of care to apply for Financial Assistance for that episode of care. D. Amounts Charged to Patients 1. Patients who receive financial assistance may not be charged more for the same services generally billed to insured patients. The Financial Assistance discounts are separately calculated for each facility and represent the average payor yield by reviewing Medicare and commercial actual and Expected Payments (including the Patient Portion) over the prior twelve month period as demonstrated more fully on Attachment C. E. Presumptive Financial Assistance Eligibility 1. In addition to the formal Financial Assistance application process, Uninsured patients may also be presumed to be eligible for Financial Assistance for charges on Technical Services based on evidence provided via use of a third party screening tool, which may be utilized as the sole documentation source to make a Financial Assistance determination. 2. Medically Necessary charges not covered by Medicaid or indigent care programs may be presumed eligible for Financial Assistance. 3. Account balances with previously made payments may be considered for Financial Assistance if requested through Patient Financial Services or Patient Accounts Customer Service; however, they shall not be considered through the presumptive Financial Assistance process. F. Billing and Collection Efforts 1. The Billing and Collections policy and translated copies can be obtained:
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Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Financial Assistance a. online at https://www.ochsner.org/patients-visitors/billing-and-financialservices/financial-assistance/ or b. upon written request at Ochsner Health System Patient Financial Services 1514 Jefferson Highway, New Orleans, LA 70121. 2. Ochsner will not impose extraordinary collection efforts such as wage garnishment, liens on primary residences or other legal actions for any patient without first making reasonable efforts to determine whether that patient is eligible for Financial Assistance under this policy. G. Communication of the Financial Assistance Program to Patients and Within the Community 1. Information about the Financial Assistance program can be found on patient billing statements, the Ochsner web site, by visiting Patient Financial Services located at the Ochsner facilities, or on the patient discharge summary. VI.
Enforcement and Exceptions A. Failure to comply with this policy may result in progressive discipline up to and including termination of employment for employees or termination of contract or service for third-party personnel, students or volunteers.
VII. Internal References OHS.REV.044 Billing and Collections policy VIII. External References HFMA 501(c)(3) Hospital Charity Care Policy and Procedure Census Bureau Measure of Poverty https://www.census.gov/hhes/www/poverty/about/overview/measure.html 42.U.S.C. 1395dd 26 U.S.C 501, see also 26 CFR Parts 1, 53 and 602, Additional Requirements for Charitable Hospitals; Final Rule
IX.
Policy History OHS.REV.042 Financial Assistance (July 2014)
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Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Financial Assistance X.
Approved
Warner Thomas, President and Chief Executive Officer
Scott Posecai, Executive Vice President and Chief Financial Officer Reviewers Stephanie Wells, System Vice President Revenue Cycle Services Katherine Cardwell, AVP Revenue Cycle System Policy Review Committee, 10/26/2015
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Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Ochsner Medical Center- Baton Rouge and clinics Fees for professional services rendered by the providers listed below are not covered by Ochsner’s Financial Assistance Policy. Aaron J. Champagne, CRNA Aaron Kyle Nettles, CRNA Adam D. Rulnick, MD Adam W Harris, MD Adrian P Aucoin, MD Alessandra A. Cashio, PA-C Alexander Isaiah Waters, CRNA Alexandra Rae Theriot, PA-C Alicia W Brand, PA-C Alison Marie Robinette, MD Amanda Searle, NNP Amber B. Verdun, NNP Amir Ali Fassihi, MD Amy Lopez Rhoades, NNP Amy M. Johnson, CRNA Angela King, MD Ann Anh Tran, MD Arati Khanna, MD Armando Sergio Garza, MD Aubrey S Thompson, CRNA Baruch Bernard Goldstein, MD Beau Michael Bergeron, MD Benjamin W. Strong, MD Bonnie Louise Anderson, MD Brad James Hymel, MD Brandi P Flanagan, NP Brent Beard, CRNA Bridget Howald Pancoast, PA-C Callie Simoneaux Dorn, CRNA Cara Cantelli Quin, MD Carmen L Fields, CRNA Cathleen Ann Ivy, MD Chad J. Aultman, MD Chad Paul Gautreaux, CRNA Charles Frederick Segura, CRNA Charles Stephen Henry, MD Cherie Adams, NNP Christiane M Patterson, CRNA Christina Sharon Geatrakas, MD Christine Anne Lamoureux, MD Christopher Charles Keaton, NP Page 1 of 19 Last updated, 11/1/2017
Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s) Christopher William Park, MD Claudia M Stevens, CRNA Clement Chun-Gar Wen, MD Cristina Margarita Cavazos, MD Dana Lynn Trahan, CRNA Daniel Huang, PA-C Daniel Aaron Strauchler, MD Daniel Anthony Dolewski, MD Daniel L Butler, MD Danielle Marie Weems, MD Dariusz Piotr Bulczak, MD Darlene Hardy, CRNA Daron Victor Brabham, CRNA Dipti Nevrekar, MD Donald Thomas Nicell, MD Douglas E. Hughes, MD Elaine Grace Khatod, MD Elizabeth Nicole Guarino, PA-C Ellen Rose Blatt, MD Emily V. Cassidy, MD Emma L. Hodgkins, NNP Eric D Chapman, MD Eric Stephen Postal, MD Erin LeBourgeois, NNP Evan T. White, CRNA Ghulam Mustafa Arain, MD Glenn A Mason, MD Heather Gallman Strittmatter, MD Hershel Fisk Morris, CRNA James Sharpless, MD James D. Fletcher, MD James M Fenn, MD Jason Shou, MD Jason A. Brown, MD Jason Marc DiPoce, MD Jeffrey A. Demouy, MD Jeffrey G. Zorn, MD Jenna M Bourgeois, MD Jennifer Warr, CRNA Jodie Johnson, CRNA John Douglas Sparks, MD John Edward Crouch, MD John Frank Termini, MD Jon Van Schellack, MD Jonathan M Andermann, MD Jonathan Patrick Coll, MD Page 2 of 19 Last updated, 11/1/2017
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s) Judy Maddox, CRNA Julie Kathleen Shaffrey, MD Justin M Vermeulen, CRNA Karen S. Caldemeyer, MD Karey Ann Gleason, CRNA Karl Matthew Nettles, MD Katherine Manzella Templeton, NP Kathrine R McGehee, NNP Kathryn Marie Tetreault, CRNA Kathryn Rankin Wagner, MD Kayla L. Zumo, PA-C Kelcey Dawn Elsass, MD Kenneth K Lo, MD Kevin Michael Blackwood, MD Kevin Peter Rudny, MD Kimberly Joyce Burkholz, MD Kirk M Bailey, MD Kristen L Spence, CRNA Kristie L Firmin, PA-C Kristin Leigh Casey, MD Kurtis Lee Tedesco, MD LaTania Z Austin, CRNA Lauren Elizabeth Carter, CRNA Lee Brown, NNP Lindsay G Williams, CRNA Lisa A. Spillers, PA-C Lloyd F. Locascio, MD London C. Guidry, MD Manal M. Schoellerman, MD Marene Shepherd, CRNA Mary A Boland, PA-C Mary Maitland Deland, MD Matthew P. Williams, CRNA Max Rosenberg Pollock, MD Micah Joel Metrailer, CRNA Michael Chien-yu Lin, MD Michele R. Thibodeaux, NNP Michelle Goni, MD Michelle Karen Melotti, MD Mihaela Ivan, MD Mitch Ewen, CRNA Monique Leona Consoer, NP Muddassir Sana, MD Neil Edward Staib, MD Omar Ahmad Mahmood, MD Patrick Holwager, CRNA Page 3 of 19 Last updated, 11/1/2017
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s) Penny Blanchard, NNP Rebecca Z Hunt, NP Reem S Awwad, MD Richard D Hanson, MD Richard Todd Kaplan, MD Rizwan Ali, MD Robert A. Aitken, MD Robert Brian Fortuna, MD Robert M. Branstetter, MD Robert P Albares, CRNA Robert W Miller, MD Roland O Okungbowa, CRNA Ronald Scott Sonken, MD Roy F Brabham, MD Russell Timothy Courtney, MD Ryan A. Davis, CRNA Safwan Khader, MD Sai Praveen Haranath, MD Sandra Parada-Orrego, MD Sandra JeanAllen Rhoden, MD Sang-Ting Tsai, MD Sanjeevi Vridhachalam, MD Sara Ann Martin, MD Sarah K Burns, CRNA Scott Fowler, CRNA Seth P. Roussel, MD Shailendri E Philip, MD Shannon Romeo Desharnais, CRNA Shanshan Bao, MD Shawn Ibrar Ahmed, MD Stephanie Sue Heinlen, MD Stephen Adam Fine, MD Steven Bryan Edson, MD Steven Ward Davis, MD Sumeet Verma, MD Susan Conway, MD Tal Baruch Delman, MD Taro Aikawa, MD Tiffany Moore Bourgeois, MD Toseef Muzaffar Khan, MD Tyler G Borne, CRNA Vibhu Kapoor, MD Victoria Alexandra Nguyen, DO Waikeong Patrick Wong, MD William Joseph Wong, MD William Michael Boedefeld, MD Page 4 of 19 Last updated, 11/1/2017
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
William R Rufini, CRNA Yulia Lisenko Bronstein, MD
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Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Ochsner Baptist and clinics Fees for professional services rendered by the providers listed below are not covered by Ochsner’s Financial Assistance Policy. Adam D. Rulnick, MD Adam Ross Hecht, MD Alan J Stolier, MD Alison Marie Robinette, MD Alyce L. Ittmann, CRNA Amir Ali Fassihi, MD Amy P. Lane, CST Angela Pizzo Lama, CRNA Aprile Brown Gibson, MD Ashfaq A. Qureshi, MD Benjamin W. Strong, MD Betty Clavijo Bennett, NP Blythe Perry Craft, DNP Christina Sharon Geatrakas, MD Cristina Margarita Cavazos, MD Cynthia Parent Mauras, OT Dariusz Piotr Bulczak, MD David N Adams, MD Devon G. Beltz, CRNA Donald Thomas Nicell, MD Douglas E. Hughes, MD Elaine Grace Khatod, MD Eric Stephen Postal, MD Erin A McGee, CRNA Erin S. Murphy, CRNA Gerhard Salomo Mundinger, MD Glenn A Mason, MD Gregory Wayne Wolfe, MD Heather Anne Erhard, MD Heidi Joseph Schexnayder, OT James E. Craigie, MD Jamie P. Reyes, NP Jannell Francine Henderson, MD Jason Marc DiPoce, MD Jean-Paul Dym, MD Jeffrey G. Zorn, MD Jeremy Freeman Schnell, CSFA Joe E. Parkey, MD John Duc Nguyen, MD Joshua Dennis Morais, MD Juan Jose Gilbert Fernandez, MD Page 6 of 19 Last updated, 11/1/2017
Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Julie Burnett Ayers, CRNA Karen Fray Monroe, CRNA Karen S. Caldemeyer, MD Kathryn Rankin Wagner, MD Kentucky Raley Skinner, CSFA Ketan Chandrakant Davae, MD Kimberley Sloan Miller, MD Kimberly Joyce Burkholz, MD Kristin Leigh Casey, MD Larry H Hollier, MD Lena J. Al-Dujaili, MD Lionel Andrew Branch, MD Lisa P. Germain, DDS Lynn M. Crefasi, RNFA Michelle F. Midkiff, NP Michelle M. Austin-Hosli, CRNA Michelle Roy Corn, CRNA Monte Frederick Zarlingo, MD Nora Brandon, CRNA Olivia C. Lee, MD Patrick B. Dauterive, CRNA Patrick Joseph Moran, CRNA Patrick Michael Dennis, MD Paul Anthony Molbert, CRNA Phoebe H. Dann, MD Prashanthi Atluri, MD Robert Malcolm Morley, DO Sai Praveen Haranath, MD Sandra JeanAllen Rhoden, MD Shailendri E Philip, MD Shannon R. Smiley, CRNA Shelly Jain, MD Stacy B Maggio, SA-C Steven Bryan Edson, MD Steven Ward Davis, MD Talaat H. Mohamed, MD Taro Aikawa, MD Waikeong Patrick Wong, MD
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Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Ochsner Medical Center- Kenner and clinics Fees for professional services rendered by the providers listed below are not covered by this Financial Assistance Policy. Adam Sciuk, MD Adam Ross Hecht, MD Adam W Harris, MD Alan David Kaye, MD Alan Joseph Fred Kopp, MD Alison Marie Robinette, MD Amir Ali Fassihi, MD Ann Anh Tran, MD Aprile Brown Gibson, MD Armando Sergio Garza, MD Barbara L Cohn, MD Baruch Bernard Goldstein, MD Benjamin W. Strong, MD Cathleen Ann Ivy, MD Chad J. Aultman, MD Charles Stephen Henry, MD Charles Van Sanders, MD Chontel M Carter, NP Christopher William Park, MD Clement Chun-Gar Wen, MD Craig Alexander Dates, MD Craig Alfred Wills, PA-C Daniel Aaron Strauchler, MD Dariusz Piotr Bulczak, MD David Duke Burdette, MD Delphia Mathilda Clarke, MD Dipti Nevrekar, MD Douglas E. Hughes, MD Elaine Grace Khatod, MD Eleanor Chu, MD Ellen Rose Blatt, MD Fredro Knight, MD Gregory Wayne Wolfe, MD Hannah Leigh Richards, PA-C Heather Gallman Strittmatter, MD Ira Walter Padnos, MD James D. Fletcher, MD James Haskew Turner, MD Jannell Francine Henderson, MD Jason Shou, MD Jason A. Brown, MD Page 8 of 19 Last updated, 11/1/2017
Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s) Jason Marc DiPoce, MD Jean-Paul Dym, MD Jeffrey A. Demouy, MD Jeffrey G. Zorn, MD Jessica Ann Borne, MD John Douglas Sparks, MD Jonathan Patrick Coll, MD Joshua Dennis Morais, MD Julie Kathleen Shaffrey, MD Karen S. Caldemeyer, MD Karl Matthew Nettles, MD Kathryn Rankin Wagner, MD Kelcey Dawn Elsass, MD Kenneth Eugene Vogel, MD Kenneth Francis Mancuso, MD Ketan Chandrakant Davae, MD Kevin Michael McDonnell, MD Kevin Peter Rudny, MD Kimberley Sloan Miller, MD Kriste Lusk Parent, NP Kurtis Lee Tedesco, MD Lee A. Lambert, MD Lindy Brooke Babin, PA-C Lionel Andrew Branch, MD Lloyd F. Locascio, MD Manal M. Schoellerman, MD Marc Howard Paul, MD Max Rosenberg Pollock, MD Melville Quincy Wyche, MD Michael Chien-yu Lin, MD Michael Joseph Cotugno, MD Michael Kevin Novick, MD Michael L Barton, MD Michelle Goni, MD Michelle Karen Melotti, MD Mihaela Ivan, MD Monte Frederick Zarlingo, MD Olivia C. Lee, MD Omar Ahmad Mahmood, MD Paul David Monsour, MD Prashanthi Atluri, MD Rhonda Faye Kendrick, MD Richard D Hanson, MD Robert Brian Fortuna, MD Robert M. Branstetter, MD Robert W Miller, MD Page 9 of 19 Last updated, 11/1/2017
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Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Ryan Norman Majoria, MD Sang-Ting Tsai, MD Sanjeevi Vridhachalam, MD Scott Beacham Schuber, MD Scott P Mackey, DO Sister Mary M. Baudier, MD Stephanie Sue Heinlen, MD Stephen Adam Fine, MD Stephen George Fox, MD Steven Bryan Edson, MD Steven Ward Davis, MD Susan Jane Berry, MD Tal Baruch Delman, MD Taro Aikawa, MD Terry A., Freiberg, DPM Thomas Kimbell Judd, MD Toseef Muzaffar Khan, MD Veronica Robvais, NP Vibhu Kapoor, MD Viet Hoai Nguyen, MD William Joseph Wong, MD
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Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Ochsner Medical Center- Northshore and clinics Fees for professional services rendered by the providers listed below are not covered by Ochsner’s Financial Assistance Policy. Alison Marie Robinette, MD Baruch Bernard Goldstein, MD Benjamin W. Strong, MD Bert Randolph Bratton, MD Byron Lee Brewer, RNFA Carmen N Daddona, CSFA Cary Trent Donohue, DPM Cathleen Ann Ivy, MD Christina Sharon Geatrakas, MD Christine Anne Lamoureux, MD Crispin De Guzman Bolisay, MD Cristina Margarita Cavazos, MD Danielle Marie Weems, MD David N Adams, MD Destini Lynn Jones, CSFA Dionne Stein, FNP Donald Thomas Nicell, MD Donna Jill Branton, NP Douglas E. Hughes, MD Edward Massett, DDS Edward J. Blache, RNFA Elaine Grace Khatod, MD Ellen Rose Blatt, MD Eric Stephen Postal, MD Gina Payton Lagarde, MD Glenn A Mason, MD Gregory Patrick Dupont, MD James A. Loyola, DMD Jannell Francine Henderson, MD Jason Marc DiPoce, MD Jean-Paul Dym, MD Jeffrey J. Stein, NP Jeremy Freeman Schnell, CSFA Jerome C. Mauterer, CSFA Jerry Lynn Hudson, MD John Edward Crouch, MD Jonathan Wayne Warner, CSFA Joni Denley Dolhonde, CSFA Jose Antonio Lefran, MD Julie Kathleen Shaffrey, MD Karen S. Caldemeyer, MD Page 11 of 19 Last updated, 11/1/2017
Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Kathryn Rankin Wagner, MD Kentucky Raley Skinner, CSFA Ketan Chandrakant Davae, MD Kimberly Joyce Burkholz, MD Kristin Leigh Casey, MD Kurtis Lee Tedesco, MD Lindsay Marie (Passafume) Ponstein, FNP Madelyn S Rebstock, PA-C Megan Catherine Hintz, RNFA Michael A. Kimbell, CSFA Mihaela Ivan, MD Neil Edward Staib, MD Omar Ahmad Mahmood, MD Paul David Monsour, MD Reem S Awwad, MD Robert Earle Owens, MD Robert Malcolm Morley, DO Robin Beth Fischer, FNP Ronald Scott Sonken, MD Russell Laroy Westfall, DDS Sai Praveen Haranath, MD Sandra Parada-Orrego, MD Sandra JeanAllen Rhoden, MD Sebastine Izu Elendu, MD Shailendri E Philip, MD Shelly Jain, MD Sophia A. Omoro, MD Stacy B Maggio, SA-C Steven Bryan Edson, MD Steven Ward Davis, MD Sumeet Verma, MD Tal Baruch Delman, MD Taro Aikawa, MD Tina Marie McGinty, CSFA Tyler P Mancil, DPM Victoria Alexandra Nguyen, DO William E. Bishop, CST William Joseph Wong, MD Yulia Lisenko Bronstein, MD
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Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Ochsner Medical Center-West Bank and clinics Fees for professional services rendered by the providers listed below are not covered by Ochsner’s Financial Assistance Policy. Adam D. Rulnick, MD Adam Ross Hecht, MD Akio Kitahama, MD Alan Joseph Fred Kopp, MD Ann Anh Tran, MD Aprile Brown Gibson, MD Asti Pilika, MD Baruch Bernard Goldstein, MD Benjamin W. Strong, MD Carl F. Culicchia, MD Carlos A. Trujillo, MD Champa Chakraborti, MD Cherie S. Niles, MD Dariusz Piotr Bulczak, MD Demarcus Day Smith, DDS Douglas E. Hughes, MD Douglas T. Mehaffie, MD Earl J. Madere, MD Edward Wai Wong, MD Elaine Grace Khatod, MD Ellen Rose Blatt, MD Eric Stephen Postal, MD Frank Wagner, MD Glenn R Landry, MD Gregory Wayne Wolfe, MD James P. Marra, MD Jason Marc DiPoce, MD Jean A Mathis, MD Jean-Paul Dym, MD Jeffrey G. Zorn, MD Jeffrey Paul Vargo, MD Jeremy Freeman Schnell, CSFA Jerry R. Smith, MD Joe E. Parkey, MD John L. Moore, MD John M Kesler, PA-C Joni Denley Dolhonde, CSFA Joseph Paul Rumage, MD Joshua Dennis Morais, MD Juan J. Gershanik, MD Juan Jose Gilbert Fernandez, MD Page 13 of 19 Last updated, 11/1/2017
Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Jules S. Deutsch, MD Julie Kathleen Shaffrey, MD Jyoti Chakraborti, MD Karen S. Caldemeyer, MD Kentucky Raley Skinner, CSFA Ketan Chandrakant Davae, MD Kim Lange, NP Kimberley Sloan Miller, MD Kimberly Robinson, CST Kimberly Joyce Burkholz, MD Kurtis Lee Tedesco, MD Laurie Z. Darling, PhD Marc Howard Paul, MD Maria I. Bautista, MD Michael J. Helm, MD Michael R. Marble, MD Michele A. Prattini, NP Michele G. Kautzman, MD Mihaela Ivan, MD Olivier P. Thelin, MD Omar Ahmad Mahmood, MD Paul Singh Sarai, MD Reem S Awwad, MD Robert Leland Guy, MD Ronald Scott Sonken, MD Sai Praveen Haranath, MD Said Minokadeh, MD Shailendri E Philip, MD Shelly Jain, MD Stephen George Fox, MD Steven Bryan Edson, MD Steven Ward Davis, MD Tal Baruch Delman, MD Taro Aikawa, MD Thomas A. Boos, MD Truyen T. Vu, MD Victoria Alexandra Nguyen, DO Xiaoyun Shang, MD Yulia Lisenko Bronstein, MD Yves Lacassie, MD
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Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Ochsner St Anne and clinics Fees for professional services rendered by the providers listed below are not covered by Ochsner’s Financial Assistance Policy. Alan Joseph Fred Kopp, MD Alison Marie Robinette, MD Baruch Bernard Goldstein, MD Britta Meghan Gooding, MD Charles G. Shissias, MD Cristina Margarita Cavazos, MD David Duke Burdette, MD Dean Batten, MD Dean F Click, CSFA Douglas E. Hughes, MD Elaine Grace Khatod, MD Faraz Khursheed, MD Gene Francis Bergeron, APRN James Haskew Turner, MD Jason Marc DiPoce, MD Javaad Ahmad, MD Jennifer J. Prados, PA-C Joe E. Parkey, MD John David David Theriot, APRN Jon Peter Engbretson, MD Joshua Dennis Morais, MD Karen S. Caldemeyer, MD Kelsey Aline Eschette Pierce, CSFA Kimberley Sloan Miller, MD Kurtis Lee Tedesco, MD LaTai E Grant Brown, MD Laurie Lynn Gutstein, MD Liat Kaplan, MD Meryn Allen Olivier, NP Michael A Couvillon, NP Michael Joseph Cooney, MD Michelle Goni, MD Mihaela Ivan, MD Paul Singh Sarai, MD Peter Matthew Reuss, MD Randall J. Wright, MD Richard Lee Toothman, MD Ron A Shatzmiller, MD Sandra Parada-Orrego, MD Sarah Pontiff Romero, FNP Shelly Jain, MD Page 15 of 19 Last updated, 11/1/2017
Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Steven Bryan Edson, MD Steven Emmet Ciabattoni, MD Steven Ward Davis, MD Tal Baruch Delman, MD Taro Aikawa, MD Thomas Frederick Fiorito, MD Thomas Henry Vreeland, MD Vibhu Kapoor, MD Yulia Lisenko Bronstein, MD
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Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
OCHSNER CLINIC FOUNDATION Fees for professional services rendered by the providers listed below are not covered by Ochsner’s Financial Assistance Policy. Abigail E. Chaffin, MD Adam D. Rulnick, MD Adam Ross Hecht, MD Alan Joseph Fred Kopp, MD Alison Marie Robinette, MD Amy S Sawyer, DDS Andrew B. Sholl, MD Ann Anh Tran, MD Aprile Brown Gibson, MD Asti Pilika, MD Baruch Bernard Goldstein, MD Benjamin W. Strong, MD Byron Lee Brewer, RNFA Carmen N Daddona, CSFA Dariusz Piotr Bulczak, MD David Allen Dionne, NP David N Adams, MD Douglas E. Hughes, MD Elaine Grace Khatod, MD Ellen Rose Blatt, MD Gregory Patrick Dupont, MD Gregory Wayne Wolfe, MD Jeanne L Pipsair, PA-C Jean-Paul Dym, MD Jeffrey G. Zorn, MD Jeffrey Paul Vargo, MD Jerome C. Mauterer, CSFA Joe E. Parkey, MD John Joseph Schmieg, MD Jonathan Wayne Warner, CSFA Joseph Caspi, MD Joshua Dennis Morais, MD Karen S. Caldemeyer, MD Kenneth K Lo, MD Ketan Chandrakant Davae, MD Kim Mayhall, MD Kimberley Sloan Miller, MD Kimberly Joyce Burkholz, MD Kurtis Lee Tedesco, MD Laura Robinson Kidd, MD Page 17 of 19 Last updated, 11/1/2017
Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Leah G Jacob, MD Marc Howard Paul, MD Megan Catherine Hintz, RNFA Michael A. Kimbell, CSFA Mihaela Ivan, MD Morrison Curtis Bethea, MD Nadja K Falk, MD Omar Ahmad Mahmood, MD Paul Singh Sarai, MD Perveshinder Hani Grewal, MD Phoebe H. Dann, MD Ralph Raymond Chesson, MD Reem S Awwad, MD Ronald Scott Sonken, MD Sai Praveen Haranath, MD Sebastine Izu Elendu, MD Shailendri E Philip, MD Shelly Jain, MD Stacy B Maggio, SA-C Stephen George Fox, MD Steve Nelson, MD Steven Bryan Edson, MD Steven Ward Davis, MD Tal Baruch Delman, MD Taro Aikawa, MD Victoria Alexandra Nguyen, DO William E. Bishop, CST Yukihiro Nakanishi, MD Yulia Lisenko Bronstein, MD Zhenggang Xiong, MD, PhD
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Page 18 of 19 Last updated, 11/1/2017
Attachment A Professional Services Not Covered by Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
OUTPATIENT SURGERY SUITE-SLIDELL Fees for professional services rendered by the providers listed below are not covered by Ochsner’s Financial Assistance Policy. Edward L. Donaldson, DDS
Page 19 of 19 Last updated, 11/1/2017
Financial Assistance Process & Application The Ochsner Health System (“OHS”) is committed to providing financial assistance for patients with a demonstrated financial need or hardship, who have received medically necessary healthcare services provided by OHS. Medically necessary services are services that are reasonable or necessary for the diagnosis or treatment of an illness or injury. Medical necessity will be determined by the examining physician. This application does not serve as a guarantee of financial assistance or reduction in outstanding liability. Forms to include: • •
OHS Financial Assistance Application OHS Patient Attestation
Documentation to include: 1) Copy of most recently filed income tax return, or 2) Copy of three (3) most recent pay stubs. a. If unemployed, please provide letter from last employer OR copy of unemployment award letter OR letter certifying denial of unemployment benefits from applicable state department of labor 3) Copy of Social Security Administration monthly award letter 4) Copy of Disability monthly award letter 5) Copy of healthcare insurance card/information 6) Any and all other income: a. Spousal/Child Support b. Rental Property c. Investment Income 7) Medicaid denial letter from state administrator Proof of dependents Please Mail Completed Info to: Ochsner Health System Attn: ________________ 1514 Jefferson Hwy New Orleans, LA 70121
Income Information: Please complete the income information below. Please state if the income listed is per month or per year.
If married, please include spouse income information under the Co-Applicant fields
Income Sources
Employment Social Security Disability Unemployment Rental Property Investment Income Spousal Support Child Support
Applicant $ $ $ $ $ $ $ $
Per Month/Year
Co-Applicant $ $ $ $ $ $ $ $
Per Month/Year
Total Combined Income $
Applicant(s) Information Applicant/Guarantor Information Relationship to patient:
Marital Status (*):
[ ] Self [ ] Spouse [ ] Parent
[ ] Single [ ] Married [ ] Divorced [ ] Separated
* If Married, please include spouse information and income
Last Name Date of Birth
First Name Number of Dependents
Middle Initial Age of Dependents
Street Address
[ ] Yes
U.S. Citizen
Current Telephone Number
City, Parish, State
Current Employer
[ ] No
City, Parish, State
ZIP
Position
If you are not working, how long have you been unemployed?
Co-applicant Information Relationship to patient: [ ] Self [ ] Spouse [ ] Parent Last Name Date of Birth
First Name Number of Dependents
Middle Initial Age of Dependents
Street Address Current Employer
[ ] Yes
U.S. Citizen
Current Telephone Number
City, Parish, State City, Parish, State
If you are not working, how long have you been unemployed?
[ ] No
ZIP
Position
Attestation
•
I have complied with the Ochsner Medical Cost Assistance Program (“MCAP”) screening process to determine if I may be eligible for alternate resources (COBRA, Social Security, Medicaid, and Victim of Crime).
•
I understand that until I have complied with the MCAP eligibility process, or applicable application process, I will not be eligible for financial assistance.
•
I understand that balances due to non-medically necessary services, such as purely elective or cosmetic services are not eligible for financial assistance, and I have not included any of those balances in this request.
•
If I have included balances due to purely elective or cosmetic services, they will not be adjusted. If they are adjusted in error, they will be reinstated.
•
If applicable, I have provided my most recent/current Insurance card with appropriate information to submit past, present, and future claims.
•
I have provided all requested documentation from page 1 of this application. I attest that all information provided on this application, as well as all supporting documents are accurate and truthful to the best of my knowledge and ability.
Printed Name
Signature
Date of Application
Phone/Contact
Address (Street Address, City, State, Zip) Attachment(s) Ochsner Financial Assistance Program
No Income Verification / Statement of Support ________________________ (Applicant) is applying for financial assistance with the Ochsner Health System. The applicant has stated they do not receive any monthly/yearly income. The applicant has listed you as their sole means of support. To the best of my knowledge, the applicant has no income and I certify this to be true. I am either providing the applicant with food and shelter and/or providing the applicant with financial support as specified below ________________________________________________ _______________ (Relationship to the applicant-for example: Shelter, Mother, Father, Other) I am providing: •
Food and Shelter
$______________
•
Financial Support
$_______________ Approximate monthly total
•
Other
$_______________ Approximate monthly total
Approximate monthly total
Printed Name (of supporter)
Signature (of supporter)
Date
Phone/Contact
Address (Street Address, City, State, Zip) If you have any questions or concerns, you may contact the Patient Accounts Customer Service department by phone at 504-842-4190. Ochsner Health System Attn: ________________ 1514 Jefferson Hwy New Orleans, LA 70121
Attachment C Amounts Generally Billed Discounts Financial Assistance Policy Policy Number Date of Issue Review Dates Revision Dates Policy Owner(s)
Page 1 of 1 Last updated, 01/2018
OHS.REV.042 07/2014 07/2014 07/2014, 02/2016 Patient Financial Services
Facility
Calculated Discount Rate
Jeff Hwy, Baptist, & Westbank
68%
Baton Rouge
71%
Kenner
75%
Northshore
80%
St. Anne
47%
Physician Charges
Calculated Discount Rate
Jeff Hwy, Baptist, & Westbank
58%
Baton Rouge
58%
Kenner
58%
Northshore
58%
St. Anne
58%
Attachment D Facilities Covered by Financial Assistance Policy Policy Number OHS.REV.042 Date of Issue 07/2014 Review Dates 07/2014 Revision Dates 07/2014, 02/2016 Policy Owner(s) Patient Financial Services OHS.REV.042 applies to the following hospital facilities and the associated provider based departments of each: Ochsner Medical Center Ochsner Baptist Medical Center Ochsner Medical Center - Baton Rouge Ochsner Medical Center - Kenner Ochsner Medical Center - North Shore Ochsner St. Anne General Hospital Ochsner Medical Center - West Bank