As part of the effort to comply with 501(r) requirements, many non-profit organizations may choose to utilize presumptive eligibility determinations within their financial assistance policies (FAPs) to proactively identify patients in need of assistance. While presumptive eligibility processes are not required by 501(r), organizations that elect to use such a policy are required to include language within their FAP that describes the sources that staff may use to make presumptive determinations (e.g., patient enrollment in local assistance programs) and the circumstances under which they may be made. Because of the often-personal nature of the sources used in such determinations, staff may potentially encounter patient inquiries and concerns regarding the types of information that will be reviewed and how eligibility is determined.
In light of this, The Academy has compiled example scripting intended to assist front- and back-end staff as they educate patients about what presumptive eligibility is, how it is used, what resources may be reviewed to make determinations, and more.
Q: What is presumptive eligibility?
Presumptive eligibility is a process that healthcare systems may use as a courtesy to the patient to determine whether patients qualify for free or discounted care before they submit a financial assistance application. To help make an informed decision, hospital staff may review previous eligibility determinations, program enrollment resources, and/or other information to verify your financial need. If you qualify, hospital staff will automatically write off or adjust your balance, depending on the level of financial assistance you qualify for.
Q: When is presumptive eligibility used?
Healthcare providers recognize that patients lead busy lives and may not have the time or ability to easily access the necessary information to support an eligibility determination. Therefore, to help make the process easier for you, a healthcare organization may rely on external resources to determine your eligibility in these circumstances. That said, the provider is not obligated to do so, and it is strongly recommended that you submit a financial assistance application before, during, or after you receive treatment.
Q: Are the resources that the healthcare system uses reliable?
Yes, they are reliable. Hospital staff will determine your eligibility by reviewing whether you qualify for other programs, such as unfunded or local assistance programs, food stamps, subsidized school lunch programs, state-funded prescription medication programs, and more. We may also grant eligibility based on your current life circumstances, such as if you are homeless, live in low-income or subsidized housing, or were referred to us from a clinic where you received free care.
We may also use previously granted financial assistance eligibility to support a determination. However, if there is no evidence available to support your eligibility, we may also partner with a vendor to help with presumptive eligibility to help identify if you are in need of assistance.
Q: What is a presumptive eligibility vendor?
It is a third-party organization that uses predictive models and public record databases, such as credit bureau and demographic databases, to assign patients a financial capacity score and determine your eligibility. We utilize our eligibility vendor when we have reason to believe that a particular patient is in financial need, but we do not have sufficient information to make a determination.
Q: I am not sure I feel comfortable with my credit being checked. Why is this necessary?
I understand your concern, but I can assure you that we only utilize our vendor’s services after all other efforts to determine your eligibility have been exhausted. As a non-profit organization, part of our mission is to ensure that quality healthcare is accessible to all. By doing this, we hope to lessen the financial burden on patients who are in need and provide assistance prior to pursuing any extraordinary collection actions on your account.
Q: How will I know if I am determined to be eligible?
If you are determined to be eligible for financial assistance, we will send you a written notification explaining that your account has either been written off or adjusted and the basis of our determination. Unless you receive free care, we will also provide information about how you may apply for more generous assistance through our financial assistance policy and where you may obtain an application.
Patient access staff are in a critical position to explain certain financial processes to patients, which can help patients feel more informed about their care. By utilizing empathetic customer service skills and scripting that can guide their patient interactions, front-end staff may relay accurate, helpful information about the presumptive eligibility process to patients.