Patient Balance After Insurance and a Financial Assistance Request
A patient with a high-deductible commercial plan ($4,000 deductible, $1,500 remaining) has a $2,900 outpatient procedure. The payer allows $1,900, applies $1,500 to the deductible, and pays 80% of the remaining $400 ($320), leaving a patient responsibility of $1,580 (deductible + 20% coinsurance). The patient calls 10 days after the statement, says she cannot pay $1,580, and asks for a 'discount.' She mentions she is a single mother working part-time and asks whether the hospital 'has a program.' The account is 10 days past statement, not yet in collections. The hospital's financial assistance policy (FAP) uses a sliding scale up to 400% of the federal poverty level; the patient's stated income is roughly 210% FPL. The front desk previously told her 'we don't really do discounts.'
1. What should the representative do with the patient's request, and what was wrong with the earlier statement?
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The earlier statement ('we don't really do discounts') was wrong and created a compliance and patient-relations problem. The hospital has a written FAP with a sliding scale to 400% FPL; at ~210% FPL the patient may qualify for a partial reduction.
Correct actions:
- Screen her against the FAP - request the documentation the policy requires (income, household size) and process the application. Do not characterize the program as a 'discount'; it is financial assistance.
- Do not condition assistance on payment or pressure her into a payment plan before the FAP determination.
- Explain the balance clearly: $1,500 deductible + $320 coinsurance = $1,580. The $1,580 is legitimately her responsibility under her plan; the FAP addresses her ability to pay it, not whether it is owed.
- Document the call and the FAP referral.
- Correct the record on the earlier misinformation and flag it to the supervisor - repeated misstatements about FAP availability are a regulatory exposure (and, for tax-exempt hospitals, a 501(r) issue).
2. The patient asks whether she can just pay $50 a month. How should the representative respond while the FAP is pending?
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Offer a path that does not foreclose the FAP:
- Set up a short-term payment arrangement (e.g., $50/month) with a documented start date, and state clearly that it is interim while the FAP application is reviewed.
- Do not require her to choose between the payment plan and financial assistance; both can proceed.
- Explain what happens if the FAP is approved: the balance may be reduced retroactively and payments already made applied to the revised balance (per policy), and the plan adjusted accordingly.
- Put the account on hold from collections while the FAP is pending - sending a patient to collections during an open FAP application is a serious compliance and reputational risk.
- Confirm the arrangement in writing (letter or portal message) so there is no dispute later about what was promised.