1. 501(r) (6) - ECA & Creating Collection Policy

2. Shawn Gretz VP of Sales for Americollect and AmeriEBO I am not a lawyer, nor do I play one on TV, and I did not stay at a Holiday Inn last night. People seeking legal advice should always consult with an attorney.

3. Thanks IRS!

4. Remarkable!

5. Extraordinary Collection Actions Remarkable Collection Actions Exceptional Collection Actions Amazing Collection Actions Sensational Collection Actions Stunning Collection Actions Incredible Collection Actions Phenomenal Collection Actions

6. Really IRS!

7. 60 Hours to Implement 60 hours per recordkeeper of up-front time to update information systems and draft and amend policies, procedures, and template billing statements and notifications, plus 15 hours per recordkeeper per year for each of three years to implement the collection of information requirements. This results in a total of 105 hours over a three-year period. (Page 6)

8. Be on the Lookout for: 1.(Page #) Location of the information that I am providing to you from the final release of the 501(r). 2.Suggestions 3.Questions 4.Checklists – Americollect is preparing some checklists. Stop by after this presentation and provide me with your information and I can send you the checklists.

9. Background

10. Effective Date Effective Date: Rely on the proposed 2012 and 2013 regulation but regulations are required to be fully implemented by the hospital organization's first taxable year beginning after December 29, 2015 (Page 13)(Page 178)

11. History - 501(r) 4,5,6 501(r) enacted March 23, 2010 part of ACA Proposed Regulations on requirements described in 501(r)(4) – (r)(6) (June 22, 2012) Comment period for Proposed Regulations ended September 24, 2012 Public hearing conducted December 5, 2012 Comment period closed July 2, 2013 Final released December 29, 2014

12. 501(r)(6) – Extraordinary Collection Actions May not engage in “extraordinary collection actions” before an organization has made “reasonable efforts” to determine whether individual is eligible for financial assistance for the care provided.

13. ECA What are ECAs? (Page 128) (1) Reporting adverse information about the individual to consumer credit reporting agencies or credit bureaus. (Page 130) (2) Actions that require a legal or judicial process, including but not limited to- (a) Commencing a civil action against an individual ; (b) Garnish an individual's wages; (c) Place a lien on an individual's property; (d) Foreclose on an individual's real property; (e) Attach or seize an individual's bank account or any other personal property; (f) Cause an individual's arrest; and (i) Cause an individual to be subject to a writ of body attachment;

14. ECAs What are ECAs? (Page 128) (3) Upfront collections before medically necessary or emergency care. (Page 134) Upfront collections on a prior medical bill unless the hospital facility can demonstrate that it required the payment from the individual based on factors other than and without regard to nonpayment of past bills. (Page 135) (4) Deferral or Denial of Care based upon nonpayment of one or more bills for previously provided care (120 rule does not count in this instance) provided however that the responsible individual be able to apply for FA immediately. (Page 168) The specific notification requirement for denying or deferring care can be satisfied if the hospital provides a copy of its FAP application form to the individual, notifies him or her that financial assistance is available, and provides the deadline after which it will not accept a FAP application for the previously provided care. The individual must have at least 30 days to submit a FAP application for the previously provided care after receiving this notice. If a FAP application is timely submitted, then the hospital must process it on an expedited basis. (5) Listing with a debt buyer (because you have less control over the debt according to the Treasury Department) (Page 132).

15. NOT ECA What are NOT ECAs? (Page 128) (1) Listing with a collection agency. (2) Calling a patient by telephone. (3) Writing off the account to Bad Debt. (4) Sending a patient a bill. (5) Upfront Collections for the current care(Page 134)

16. NOT ECA What are NOT ECAs? (Page 128) (6) Charging interest on a medical debt. (Page 133) This is considered an extension of credit. (7) Filing a claim in a bankruptcy proceeding (Page 154) (8) The proceeds of settlements, judgments, or compromises arising from a patient’s suit against a third party who caused the patient’s injuries come from the third party, not from the injured patient, and thus hospital liens to obtain such proceeds should not be treated as collection actions against the patient. In addition, the portion of the proceeds of a judgment, settlement, or compromise attributable under state law to care that a hospital facility has provided may appropriately be viewed as compensation for that care. (Page 130) (9) Many other items that cannot be listed because the list would be too large

17. Reasonable Effort 1. Plain Language Summary: The requirement to provide a plain language summary of the FAP as part of the discharge or intake process is included under § 1.501(r)-4 of the final regulations as part of widely publicizing the FAP, rather than under § 1.501(r)-6(c)

18. Reasonable Effort 1. Continued Plain Language Summary: Suggestion: Train access to understand that hospital facilities only have to "offer" a plain language summary.

19. Reasonable Effort 1. Continued - Plain Language Summary: What it is- A document containing a simple explanation of financial assistance. This document will be used in three ways: 1.Mailed with the Final Notice: Required In only one post- discharge bill and only to those subset of patients whom the hospital facility actually intends to engage in extraordinary collection actions. (Page 5) 2.Conspicuous Public Displays 3.Available at Admissions and Emergency Department - FREE

20. Reasonable Effort 1. Continued - Plain Language Summary: What is required on the Plain Language Summary? (1)The direct Web site address and physical location(s) where the individual can obtain copies of the FAP and FAP application form; and (2)physical location of hospital facility staff who can provide the individual assistance about the FAP and the FAP application process, or of the nonprofit organizations or government agencies, if any, that the hospital facility has identified as available sources of assistance with FAP application. (Page 94) (3)how to apply for financial assistance (page 96) What other items would you like to add in your plain language summary (example: a statement regarding patient responsibilities)?

21. Reasonable Effort 2. Three Bills/Statements - Based on typical billing cycles reported by commenter's, should ensure patients receive at least three bills before facing an ECA. http://www.hfma.org/WorkArea/DownloadAs set.aspx?id=21228

22. Reasonable Effort 2. Continued: at least three bills Conspicuous Written Notice (Statements) Does your billing statement include a conspicuous written notice that notifies and informs the recipient about the availability of FA under the hospital FAP including the telephone number of the hospital department or facility and direct web site address where copies of documents may be obtained? (Page 5 & 91) This is also required to be of sufficient size to be clearly readable.

23. Reasonable Effort 2. Continued Three Bills/Statements – Mail Returns: "Provided" is considered to be the date it was mailed, emailed, or delivered by hand. (Page 152)

24. Reasonable Effort 2. Continued Three Bills/Statements – Will you initiate a program to convert many of your mailed statements to electronic (for example by email) to any individual who indicates he or she prefers to receive the written notice or communication electronically? (Page 151)

25. Reasonable Effort 3. Plain Language Summary: Final regulations require a plain language summary to be included with only one post-discharge communication and give a hospital facility the flexibility to send this one plain language summary only to the subset of patients against whom the hospital facility actually intends to engage in extraordinary collection actions.

26. Reasonable Effort 3. Continued -Plain Language Summary: Mailed with 1 st Statement? Mailed with 2 nd Statement? Mailed with 3 rd Statement? Mailed with Final Notice?

27. Reasonable Effort 4. Final Notice- Did you update your final notice with the “intended” ECAs also mentioning that financial assistance is available (Page 150)? Suggestion: Small Balance Accounts: Combine the third statement and the ECA notification & FAP Plain Language Summary into one statement to save cost.

28. Reasonable Effort 4. Continued Final Notice- Intended Most hospitals will have a short list: “Your account is past due and about to be listed with our collection agency partner. We will allow and intend our collection agency partner to place this account on your credit bureaus and/or take legal or judicial action.”

29. Reasonable Effort 4. Continued Final Notice- (Page 150) DEADLINE -The deadline may be no earlier than 30 days after the ECA Initiation Notice sent by mail or electronic mail.

30. Reasonable Effort 5. Oral Communication: Did the hospital facility make a reasonable effort to orally notify those patients against whom the hospital facility intends to engage in ECAs at least 30 days before they intend to initiate? (Page 146 & 149) AmeriEBO on every communication is saying: “financial assistance is available for those who qualified "

31. Reasonable Effort 5. Continued - Oral Communication: Remember that the hospital does not have to actually speak with the individual; it just must make “reasonable efforts”.

33. On the Clock No longer is the first 120 days called the notification period. It is now considered to be the time you need to make the determination of financial eligibility. If a responsible individual FAP eligibility is undetermined, then you will have to wait 120 days before pursuing ECAs. (Page 139)

34. On the Clock Clock Starts - first post discharge statement Clock Ends - 120 days from the first post discharge statement

36. Application Period Application Period: Must accept & process FAP applications during longer period that end on 240th day after hospital provides an individual with first post discharge billing statement.

37. Application Scenarios Received an Application – NOW what? 1.Approved – NOW what? a.Full Amount? b.Less Than Full Amount? 2.Denied – NOW what? 3.Missing Information – NOW what?

38. Application Period Received Application: What happens next? 1.Notify your collection agencies that you received a financial assistance application during the application period and ECAs need to be suspended? (Page 153)(Page 155) 2.How will you make eligibility determination in a timely manner? (Page 155) 3.Document the determination? 4.How will you notify the responsible individual in writing of your determination? (Page 155)

39. Application Period Approved: How will your organization notify the responsible individual that they were eligible for free care under the FAP? (Page 158) How will your organization issue refunds for payments made for a responsible individual that is eligible for financial assistance? (Page 158) $5 is the threshold that is required to be refunded. How will your organization notify your collection agency if you approved an application and ECAs have to be reversed? (Page 153)

40. Application Period Approved for less than full amount: How will your organization notify the responsible individual that they were eligible for discounted care under the FAP? (Page 158) Provide the Final Notice with 30 days to pay before initiating ECAs. How will your organization notify your collection agency if you approved an application and ECAs have to be reversed and a notice was sent to the responsible individual about resuming ECAs in 30 days and an accompanying plain language summary of the FAP? (Page 153)

41. 501(r)(6) – Application Period Not Approved: How will your organization make sure a FINAL NOTICE that is sent to the responsible individual is not approved and to resume ECAs in 30 days and an accompanying plain language summary of the FAP has been mailed?(Page 153) How will your organization notify your collection agency to resume ECAs if it has been 30 days since you provided the notice of intended ECAs and an accompanying plain language summary of the FAP if the application was not approved? (Page 153) This is only for the care at issue.

42. 501(r)(6) – Application Period Missing Information: How will your organization make sure a notice is sent to the responsible individual of the missing requirements/ FINAL NOTICE to make financial eligibility determination and to resume ECAs in 30 days and that an accompanying plain language summary of the FAP has been mailed?(Page 153) How will your organization notify your collection agency to resume ECAs if it has been 30 days since you provided the notice of intended ECAs and an accompanying plain language summary of the FAP) if the application is not completed? (Page 153) This is only for the care at issue.

43. 501(r)(6) – Application Period Timely Manner: Will your organization require a Medicaid application be filed before approval or denial of financial assistance? (Page 156) What is considered a "timely manner" to approve a financial assistance application? (Page 156) Suggestion: In my experience, “timely manner” is not a friendly language for hospitals because it can be decided by a single individual. Some could be friendly and use the upper limit of 45 days that was listed in the examples and others may say reasonable is 30 days. I would suggest trying to make the determination for financial assistance within 30 days unless the individual is applying for Medicaid coverage.

45. Parents ECA & Reasonable Effort -For and Not For. In the case of a minor (or states where marital property laws are 50/50), where both parents are responsible for the bill, you cannot engage in ECAs until reasonable effort has been determined. (Page 125)

46. Third Party ECA & Reasonable Effort -For and Not For. Individual does not include trust, estate, partnership, association, company, corporation, or governmental entity, thus, does not include any private or public insurers. (Page 126)

47. Elective For Care Covered Under FAP: Section §1.501(r)- (6)(b) of these final regulations define ECAs as actions related to obtaining payment of bills “for care covered under the hospital facilities FAP. (Page 128) Did you remove elective, non-medically necessary, and non-emergency care from your FAP?

48. Partially Eligible 501(r)(6) does not bar ECAs against individuals that have been determined to be FAP eligible. (Page 135) Example of this is a responsible individual/patient given a 75% financial assistance write-off based upon income below a federal poverty guideline. Responsible individual is supposed to pay the remaining 25%. If responsible individual does not pay the remaining 25% and it is after 120 days from the first post discharge statement and a notice was sent to responsible individual 30 days prior about the intended ECAs, then ECAS can be pursued.

49. Episodes of Care: Will you satisfy the notification requirements simultaneously for multiple episodes of care for the purpose of notifying the individual about its FAP and potential ECAs? (Page 144) This can only be the case if the most recent episode of care is past the 120 day period. (Page 145). The application period does start with each episode of care. (Page 145)

50. 501(r)(6) – Document - NO Documentation: Unlike Medicare Bad Debt, documentation is not required on each responsible party. But you do have to update your 990 to include whether and how reasonable efforts were made to determine FAP eligibility before engaging in ECAs? (Page 151)

51. Collection Agency Hospital facilities must be held accountable for the ECAs of the debt collection agency or debt buyers. (Page 127)

52. Collection Agency Do you have a contract in place with your collection agency that requires them to follow 501(r) regarding ECAs and also FAP applications? Included in the contract should be language that if the collection agency mistakenly violates 501(r)(6), they will notify/disclose to the hospital facility and correct the failure immediately. (Page 127)

53. 501(r)(6) – Update Contract 1. Disclose all failures: A hospital’s 501(r)(6) failure, based on a third party’s actions, may be excused if the failure is minor (e.g., not willful or egregious) and the hospital corrects and discloses the failure. (Page 27) 2. Will your organization’s collection agency take any of the necessary steps to make reasonable efforts determination? (Page 169) Treasury has clarified that the hospital facility will take those steps.

54. 501(r)(6) – Update Contract Collection Agency Contract 3. Wait on ECAs 4. Who will refund Patients if Approved for FA? 5. Suspend ECAs in Application Period 6. Send FA Application to Patient

55. Collection Policy Two options on how to create a “Billing and Collection Policy” 1.Update your FAP 2.Or Create a separate “Billing and Collection Policy”

56. Collection Policy Requirements 1.Describe the Actions the Hospital will take 2.Describe the Actions a collection partner may take 1.Including extraordinary collection actions (ECA) 2.But not limited to the ECAs 3.Must also describe the process and time frames the hospital facility (or other authorized party) will use in taking these actions 4.Include any reasonable efforts to determine whether an individual is FAP-eligible as described in section 501(r)(6). 5.In addition, the FAP or billing and collections policy must describe the office, department, committee, or other body with the final authority or responsibility for determining that the hospital facility has made reasonable efforts to determine whether an individual is FAP-eligible and may therefore engage in extraordinary collection actions against the individual. 6.How can individuals obtain a free copy?

57. Where to Start 1.Create a Billing and Collection Policy. 2.Calculate the AGB (Amount Generally Billed) 501r(5). 3.Create your Plain Language Summary 4.Update Statements to include Conspicuous Written Notice. 5.Gather the list of Physicians that participate and do not participate in your Financial Assistance. 6.Update your Financial Assistance Policy and Application

58. Q&A Shawn Gretz shawn@americollect.com 920-420-3420 shawn@americollect.com https://www.federalregister.gov/articles/2012/06/26/2012- 15537/additional-requirements-for-charitable-hospitals