Sliding Fee Discount Program

Procedure

The following guidelines are to be followed in providing the Sliding Fee Discount Program.

Notification: The clinic will notify patients of the Sliding Fee Discount Program by:
- Payment Policy will be available to all uninsured patients at the time of service.
- Notification of the Sliding Fee Discount Program will be offered to each patient at time of their appointment.
- Sliding Fee Discount Program application may be included with collection notices sent out by Hattiesburg Clinic.
- An explanation of our Sliding Fee Discount Program and our application form are available on the selected departments link on the Hattiesburg Clinic website.
- The Hattiesburg Clinic clinic(s) listed above places notification of Sliding Fee Discount Program in the clinic waiting areas.
All patients seeking health care services at the selected clinic above are assured that they will be served regardless of ability to pay. No one is refused service because of lack of financial means to pay.
Request for discount: Requests for discounted services may be made by patients, family members, social services staff or others who are aware of existing financial hardship. The Sliding Fee Discount Program will only be made available for clinic visits. Information and forms can be obtained from the front desk and the business office.
Administration: The Sliding Fee Discount Program procedure will be administered through the clinic manager or his/her designee. Information about the Sliding Fee Discount Program policy and procedure will be provided and assistance offered for completion of the application. Dignity and confidentiality will be respected for all who seek and/or are provided health care services.
Completion of Application: The patient/responsible party must complete the Sliding Fee Discount Program application in its entirety. By signing the Sliding Fee Discount Program application, persons authorize the selected clinic access in confirming income as disclosed on the application form. Providing false information on a Sliding Fee Discount Program application will result in all Sliding Fee Discount Program discounts being revoked and the full balance of the account(s) restored and payable immediately. If an application is unable to be processed due to the need for additional information, the applicant has two weeks from the date of notification to supply the necessary information without having the date on his/her application adjusted. If a patient does not provide the requested information within the two-week time period, his/her application will be re-dated to the date on which s/he supplies the requested information. Any accounts turned over for collection as a result of the patient’s delay in providing information will not be considered for the Sliding Fee Discount Program.
Eligibility: Discounts will be based on income and family size only. The selected clinic department of Hattiesburg Clinic uses the Census Bureau definitions of each.
- Family is defined as: a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing together; all such people (including related subfamily members) are considered as members of one family. The selected clinic will also accept non-related household members when calculating family size.
- Income includes: gross wages, salaries, tips, income from business and self-employment, unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income, interest, dividends, rental income from properties, royalties, income from estates and trusts, alimony, child support, assistance from outside the household and other miscellaneous source.
Income verification: Applicants must provide one of the following: prior year W-2, two most recent pay stubs, letter from employer, or Form 4506-T (if W-2 not filed). Self-employed individuals will be required to submit detail of the most recent three months of income and expenses for the business. Adequate information must be made available to determine eligibility for the program. Self-declaration of Income may only be used in special circumstances. Specific examples include participants who are homeless. Patients who are unable to provide written verification must provide a signed statement of income, and why they are unable to provide independent verification. This statement will be presented to the selected department’s service line director or his/her designee for review and final determination as to the sliding fee percentage. Self-declared patients will be responsible for 100% of their charges until management determines the appropriate category.
Discounts: Those with incomes at or below 100% of poverty will receive a full 100% discount. Those with incomes above 100% of poverty, but at or below 200% of poverty, will be charged according to the attached sliding fee schedule. The sliding fee schedule will be updated during the first quarter of every calendar year with the latest Federal Poverty Guidelines.
Nominal Fee: Patients with incomes above 100% of poverty, but at or below 200% of poverty will be charged a nominal fee (at this time the facility marked does not charge a nominal fee) according to the attached sliding fee schedule and based on their family size and income. However, patients will not be denied services due to inability to pay. The nominal fee is not a threshold for receiving care and thus, is not a minimum fee or co-payment.
Waiving of Charges: In certain situations, patients may not be able to pay the nominal or discount fee. Waiving of charges may only be used in special circumstances and must be approved by the selected department’s service line director, or their designee. Any waiving of charges should be documented in the patient’s file along with an explanation (e.g., ability to pay, good will, health promotion event).
Applicant Notification: The Sliding Fee Discount Program determination will be provided to the applicant(s) in writing, and will include the percentage of Sliding Fee Discount Program write off, or, if applicable, the reason for denial. If the application is approved for less than a 100% discount or denied, the patient and/or responsible party must immediately establish payment arrangements with the selected department above. Sliding Fee Discount Program applications cover outstanding patient balances for six months prior to application date and any balances incurred within 12 months after the approved date, unless their financial situation changes significantly. The applicant has the option to reapply after the 12 months have expired or anytime there has been a significant change in family income. When the applicant reapplies, the look back period will be the lesser of six months or the expiration of their last Sliding Fee Discount Program application.
Refusal to Pay: If a patient verbally expresses an unwillingness to pay or vacates the premises without paying for services, the patient will be contacted in writing regarding their payment obligations. If the patient is not on the sliding fee schedule, a copy of the sliding fee discount program application will be sent with the notice. If the patient does not make effort to pay or fails to respond within 60 days, this constitutes refusal to pay. At this point in time, the selected department can explore options not limited, but including offering the patient a payment plan, waiving of charges, or referring the patient to collections.
Record Keeping: Information related to Sliding Fee Discount Program decisions will be maintained and preserved in a centralized confidential file located in the clinic manager’s office, in an effort to preserve the dignity of those receiving free or discounted care.
- Applicants that have been approved for the Sliding Fee Discount Program will be logged in a password protected document on a clinic shared directory, noting names of applicants, dates of coverage and percentage of coverage.
- The business office manager will maintain an additional monthly log identifying Sliding Fee Discount Program recipients and dollar amounts. Denials will also be logged.
Annually, the amount of Sliding Fee Discount Program provided will be reviewed by the service line director. The SFS will be updated based on the current Federal Poverty Guidelines. Pertinent information comparing amount budgeted and actual community care provided shall serve as a guideline for future planning. This will also serve as a discussion base for reviewing possible changes in our policy and procedures and for examining institutional practices which may serve as barriers preventing eligible patients from having access to our community care provisions.
Budget: During the annual budget process, an estimated amount of Sliding Fee Discount Program service will be placed into the budget as a deduction from revenue. Board approval for Sliding Fee Discount Program will be sought as an integral part of the annual budget.

REVISED: 04-01-2020

Non-Discrimination Policy

Hattiesburg Clinic complies with applicable Federal Civil Rights laws and does not discriminate on the basis of race, color, national origin, religion, sexual orientation, gender identity, age, disability or sex. Hattiesburg Clinic:

Provides free aids and services for patients with disabilities to be able to communicate with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages

If you need these services, contact the department manager or Compliance Officer.

If you believe that Hattiesburg Clinic has failed to provide these services or discriminated in another way on the basis of race, color, national origin, religion, sexual orientation, gender identity age, disability or sex, you can file a grievance with: Hattiesburg Clinic’s Compliance Officer, 415 South 28^th Avenue, Hattiesburg, MS 39401; Phone: (601) 268-5832; Fax: (601) 261-3615; Email compliance@hattiesburgclinic.com. You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, our Compliance Officer is available to you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Policy

Purpose

Participating Locations

Procedure

Non-Discrimination Policy