Commercial Copay Collection

Effective Date: September 30, 2021

Please read the following carefully to understand Our views and practices regarding Copay Collection.

1. Policy Statement

Athelas Inc. and its Affiliates (“Athelas”) is committed to complying with federal and state laws concerning accurate billing.  At the same time, Athelas is committed to providing, or assisting its customers in providing, access to high quality health care to all patients. Athelas has encountered situations in which patients are unable to pay cost-sharing obligations owed to Athelas or its customers because of financial hardships. In some situations, patients fail to pay cost-sharing obligations despite good faith collection efforts. To address these situations, Athelas will implement this Policy and Procedure for Patient Assistance (this “Policy”).‍

‍2. Purpose

Except under certain circumstances, waivers of deductibles and copayments are not permitted because such waivers misrepresent actual charge and may result in false claims. Also, the Office of Inspector General has indicated that such waivers may violate the Federal Anti-Kickback Statute. Accordingly, this policy sets forth procedures that Athelas and all Athelas employees will follow before any cost-sharing obligation is waived for healthcare services billed by Athelas on behalf of its customers. Under this policy, Athelas may waive a patient’s cost-sharing obligation on behalf of its customers only after the patient demonstrates a financial hardship. Otherwise, Athelas will employ good faith efforts to collect copayments and deductibles.

3. Definitions

1. Application. The form entitled, “Economic Assistance Request,” that a patient must complete to request a financial hardship waiver.  The application is available at:
   
   1. OPTION 1: https://www.aafp.org/fpm/2009/0900/fpm20090900p26-rt1.pdf
   2. OPTION 2: https://www.aalabs.com/assets/pdf/Medical-Financial-Hardship.pdf 
2. Cost-Sharing Obligations. Payment obligations, including copayments, deductibles, and coinsurance, required under a patient’s arrangement with the patient’s third-party payor.
3. Family. All persons residing in a patient’s home who are related to the patient by birth, marriage, or adoption.
4. Federal Poverty Guidelines (“FPGs”). Often referred to as the “federal poverty level,” FPGs are measures of poverty issued yearly by the Department of Health and Human Services in the Federal Register.  The current FPGs may be calculated at https://home.mycoverageplan.com/fpl.html.
5. Financial Hardship Waiver. Waiver of a cost-sharing obligation provided to a patient because the patient demonstrated a financial need.
6. Gross Family Income. Gross family income refers to the total yearly value of the family’s income from all sources prior to any tax deduction.
7. Manager. Under this policy, the Manager is responsible for reviewing applications and determining whether to grant a financial hardship waiver.  The CBO will serve as the Manager under this policy. S/he may delegate his/her responsibilities under this Policy to any employee of Athelas.
8. Athelas. In this policy, references to Athelas include all employees and representatives authorized to act on behalf of Athelas.
   

4. Procedure

1. Private Insurance Companies. Athelas will comply with all contracts in place with insurance companies, where provided by Athelas customers. In the event a contract conflicts with this Policy, the contract will take precedence over this policy. 
   

2. Statements Regarding Waivers. Athelas will not advertise or otherwise promote the waiver of deductibles or copayments. No Athelas employee may tell the patient or the patient’s representative that the patient does not need to pay the cost-sharing obligation unless the patient has submitted an application and the Manager has authorized a waiver. At the time Athelas provides services to a patient, Athelas representatives will provide to the patient an estimate of the patient’s cost-sharing obligation. Only when the patient volunteers that he/she cannot pay the cost-sharing obligation may the Athelas representatives may inform the patient of the availability of a financial hardship waiver and the application process. Athelas will document any waiver provided to a patient on the patient’s invoice or receipt for service.
   
   
3. Financial Hardship Waivers.
   

1. Application Required. When a patient requests a financial hardship waiver, Athelas will require the patient to complete and submit an application entitled, “Economic Assistance Request.” If the patient requests an application for patient assistance, Athelas representatives may have patient submit hardship applications electronically. Alternatively, at the patient’s request, Athelas representatives may receive the information verbally and complete the application on behalf of the patient. Any application completed in this manner will be mailed or emailed to the patient for the patient to sign and return. The patient will also be required to supplement an application completed verbally with evidence of financial hardship.
2. Up to Date Information. Upon receipt of the application, Athelas will inform the patient of the patient’s responsibility to notify Athelas of any changes to the patient’s situation. Athelas may rely on the documentation submitted by the patient for 24 months, unless the patient notifies Athelas of any changes to his or her situation. At the expiration of the 24-month period, Athelas will request that the patient completes a new application.
3. Documentation Supplementing the Application. Athelas need not request documentation to support the patient’s statements on the application in every case.  Also, in the event the Manager has any doubts regarding the accuracy and validity of an application, Athelas will require the patient to submit documentation evidencing a financial hardship. In such events, Athelas may request a copy of the patient’s tax return and/or other evidence of the patient’s financial need, which may include evidence of (i) homelessness; (ii) enrollment in Women, Infants, and Children (WIC) programs; (iii) receipt of food stamps; (iv) participation in a subsidized school lunch program; (v) participation in an unfunded state or local assistance program; (vi) residence in low income, subsidized housing; and/or (vii) other evidence of financial need, such as pay stubs or medical bills.
4. Eligibility Criteria for Financial Hardship Waivers. The Manager will review the submitted documentation and determine whether the patient meets the criteria for a financial hardship waiver. The basis for any determination will be documented and kept in Athelas’s records. The eligibility criteria for financial hardship waivers are as follows:
   
   1. Automatic Waiver. The patient is automatically eligible for full waiver of the patient’s cost-sharing obligation if the patient’s gross family income is less than or equal to twice the applicable FPG. Under such circumstances, the patient may receive a full waiver. ‍
   2. Discretionary Waiver. If the patient’s gross family income is greater than double the applicable FPG, but other circumstances demonstrate financial hardship, Athelas may provide a discretionary waiver. The basis for any determination shall be thoroughly documented in Athelas’s records.

5. Documentation. Athelas will maintain copies of all applications and supplemental documentation submitted by patients. Athelas will document and maintain records concerning (i) the amount of a waiver provided to a patient and (ii) the basis for Athelas’s decision.
   

4. Waivers Following Good Faith Collection Efforts. Athelas may write off the cost-sharing obligation of a patient who does not qualify for a financial hardship waiver only if (i) the patient’s cost-sharing obligation remains unpaid after 120 days and (ii) Athelas exercised and documented the following collection efforts:
   
   1. Initial Invoice. After Athelas provides services to a patient, Athelas will issue to the patient electronically an invoice detailing the amount of the patient’s cost-sharing obligation. The invoice will be placed in patient’s online portal and a notice of available documentation will be sent to the patient via electronic mail.
   2. Second Invoice. If the patient fails to pay the cost-sharing obligation within 30 days, Athelas will send to the patient electronically a subsequent statement detailing the patient’s outstanding balance. The invoice will be placed in patient’s online portal and a notice of available documentation will be sent to the patient via electronic mail.
   3. Third Invoice. If the cost-sharing obligation remains unpaid after 60 days, Athelas will electronically send a third billing statement. The invoice will be placed in patient’s online portal and a notice of available documentation will be sent to the patient via electronic mail. 
   4. Fourth Invoice. If the patient’s obligation remains unpaid after 90 days, Athelas will send a fourth billing statement. The invoice will be placed in patient’s online portal and a notice of available documentation will be sent to the patient via electronic mail.
   5. Documentation. All notices regarding the patient’s cost-sharing obligation will be documented in the patient’s billing file. If a patient’s cost-sharing obligation remains unpaid after 120 days, Athelas will then direct its customer to write-off the obligation. 
   6. Secondary Efforts for Public Programs. For claims submitted under public programs, including but not limited to Medicare, Medicaid and Tricare claims only (“Public Claims”), the Third and Fourth invoice, in addition to being provided electronically, will be simultaneously mailed to the patient’s address. All invoices mailed to patients will include a phone number they can call to speak to a representative. During any phone call received, an Athelas representative will (i) collect information concerning the reason for non-payment, (ii) solicit an agreement for a specific payment plan, and/or (iii) offer to provide an application for patient assistance‍

5. Audits

The billing and waiver procedures of Athelas will be audited from time to time. Findings from such audits shall be submitted in writing to Athelas’s officers and directors. Athelas’s officers and directors may also engage an outside party to conduct an audit of Athelas.