Billing, Insurance & Payment

Valley Presbyterian Hospital is committed to providing financial assistance to patients who cannot pay for part or all of the care they receive. Consistent with our mission and values, we embrace the following principles:
  • Patients should be treated equally, with dignity, respect and compassion.
  • Concern over a hospital bill should never prevent any individual from receiving emergency health services.
  • Patients should be expected to contribute to the cost of their care based upon their individual ability to pay.
  • Hospital financial aid policies and practices will take into account each individual's ability to contribute to the cost of his or her care, as well as the hospital's ability to provide care.
  • Financial aid policies should be clear, easy-to-understand, and communicated in a way that is dignified and in languages appropriate to the community and patients served.
  • Financial aid policies should be made available to prospective and current patients and to the community at large.

Rosenthal Act

Rosenthal Fair Collection Practices Act and Federal Fair Debt Collection Practices Act:

State and federal law require debt collectors to treat you fairly and prohibit debt collectors from making false statements or threats of violence, using obscene or profane language, and making improper communications with third parties, including your employer. Except under unusual circumstances, debt collectors may not contact you before 8:00 a.m. or after 9:00 p.m. In general, a debt collector may not give information about your debt to another person other than your attorney or spouse. A debt collector may contact another person to confirm your location or to enforce a judgment. For more information about debt collection activities, you may contact the Federal Trade Commission by telephone at 877-FTC-HELP (877-382-4357) or online at www.ftc.gov.

Billing and Collection Policy

Purpose:

To insure that accounts are billed and followed up in a timely manner.

Policy:

This policy explains the Hospital's procedures related to collecting outstanding payments from patients and any insurer through which they have health insurance coverage. Some exceptions can be made, as risk management may need to hold, adjust or write off an account. Other exceptions may be granted by the Chief Financial Officer or the director of Revenue Cycle. All new staff members are trained on the process below.

Procedure:

I. Hospital Collection Efforts

A. The hospital shall make all reasonable efforts to obtain from the patient or his or her representative information about whether private or public health insurance or sponsorship may fully or partially cover the charges for care rendered by the hospital to a patient, including, but not limited to, private health insurance, Medicare, Medi-Cal, the Healthy Families program, or other state-funded programs designed to provide health coverage.

II. Insured Patients (including commercial insurers, Medicare, Medi-Cal, and all other payers)

A. After claims are submitted to insurers, whether electronically or in hard-copy form, the Patient Financial Services ("PFS") staff contacts the appropriate insurance company, either by phone or using the insurer's website, to determine when the remaining balance will be paid. If there is a secondary or tertiary insurer involved, a claim is submitted to that insurer after payment or denial is received from the primary insurer. Once all insurers have issued payment, and the account has been reviewed by a claims adjuster, any remaining balance is owed by the patient.

III. Denials

A. If an insurer denies the Hospital's request for payment, the account is either resubmitted or appealed as appropriate based on the type of denial (medical necessity, no authorization, underpayment, etc.). If the claim continues to be denied by the insurer, the Hospital may decide it is necessary to write the claim off.

IV. HRMG Communication

A. If the Hospital receives payment from an insurer and there is a remaining balance that is the responsibility of the patient ten (10) days after the Hospital receives payment from the insurer, the Hospital's Healthcare Resource Management Group (HRMG), an extension of the Hospital's Business Office, will contact the patient through a series of letters requesting payment on the account. The account remains with HRMG for 120 days, during which time they pursue payment from the patient. If after 120 days there is still an outstanding balance and no payment arrangement has been established, the account is referred to an outside Collection Agency. If a patient is attempting in good faith to settle an outstanding bill with the hospital by negotiating a reasonable payment plan or by making regular partial payments of a reasonable amount, the hospital shall not send the unpaid bill to any collection agency or other assignee, unless it has agreed to comply with Cal. Health & Safety Sec. 127425, "Debt collection policy."

V. Self-Pay (Uninsured) Patients

A. Three days after a patient's claim is coded and ready for billing, any self-pay accounts with outstanding balances are referred to the Healthcare Resource Management Group (HRMG), an extension of the Hospital's Business Office, who will contact the patient through a series of letters requesting payment on the account. The account remains with HRMG for 120 days, during which time they pursue payment from the patient. If after 120 days there is still an outstanding balance and no payment arrangement has been established, the account is referred to an outside Collection Agency.

VI. Collection Notice

A. Before commencing any collection activities, the Hospital or the Collection Agency will provide the patient with a clear and conspicuous notice outlining the patient's rights under the Rosenthal Fair Debt Collection Practices Act and the federal Fair Debt Collection Practices Act, and a statement that nonprofit counseling services may be available to the patient. The notice outlining the patient's rights shall be as follows:
  1. "State and Federal law require debt collectors to treat you fairly and prohibit debt collectors from making false statements or threats of violence, using obscene or profane language, and making improper communications with third parties, including your employer. Except under unusual circumstances, debt collectors may not contact you before 8:00 a.m. or after 9:00 p.m. In general, a debt collector may not give information about your debt to another person, other than your attorney or spouse. A debt collector may contact another person to confirm your location or to enforce a judgment. For more information about debt collection activities, you may contact the Federal Trade Commission by telephone at 1-877-FTC-HELP (1-877-382-4357) or online at www.ftc.gov.

VII. Collection Agency Efforts

A. When the Hospital is not able to collect outstanding payments from a patient or an insurer through its own reasonable efforts, it may work with an outside Collection Agency to assist in obtaining outstanding payments.

VIII. Hospital - Collection Agency Requirements

A. The Hospital may only use a collection agency that has agreed in writing to adhere to the hospital's standards and scope of practices, including the California Hospital Fair Pricing Act.

B. For any patient that is uninsured or has high medical costs, as discussed in the Hospital's Financial Assistance Policy, the Hospital, the Collections Agency or any other agent of the Hospital's Financial Assistance Policy, the Hospital, the Collections Agency or any other agent of the Hospital shall not report adverse information to a credit reporting agency or take any legal action against the patient for nonpayment less than 150 days after the patient was first billed. This timeline will be extended if the patient has appealed the bill and the appeal is pending.

C. The Hospital, the Collection Agency or any other affiliate of the hospital cannot use wage garnishments or liens on primary residences as a means of collections. This means that the Hospital, the Collection Agency, and other entities working with them cannot force you to give them your paycheck or threaten to sell a patient's primary house while the patient or certain of the patient's family members are alive to satisfy your debt to the Hospital.

Patient Payment Policy

Purpose:

To provide guidelines for payment plans in order to allow patients to make monthly payments without interest.

Policy:

Patients who are unable to pay their balance in full are given the opportunity to make monthly payments based on the balance owed with no interest.

Procedure:

I. Written Notice

A. If the Hospital bills a patient who has not provided proof of coverage by a third party at the time the care is provided or upon request, as a part of that billing, the Hospital shall provide the patient with a clear and conspicuous notice that includes all of the following:
  1. A statement of charges rendered by the Hospital;
  2. A request that the patient inform the Hospital if the patient has health insurance coverage, Medicare, Healthy Families Program, Medi-Cal, or other coverage;
  3. A statement that, if the patient does not have health insurance coverage, he/she may be eligible for Medicare, Healthy Families Program, Medi-Cal, coverage provided through the California Health Benefit Exchange, California Children's Services Program, other state or county funded health coverage, or Charity Care. Applications for such programs are available through the Hospital's Financial Counselor's Office, which can be reached at fcteam@valleypres.org or 818.902.5174.
  4. A copy of Charity Care and Discounted Care Policy (upon request)

II. Payment Plans

A. Payment Plan
  1. The collections vendor will make every attempt to have the account paid in full within three months for accounts with smaller balances, and 12 months for accounts with larger balances. For balances under $500, three monthly payments for 1/3 of the balance should be paid. If the balance is over $500, the monthly payments should be one-twelfth (1/12) of the balance for 12 months.
B. Reasonable Payment Plan
  1. If the patient and the collections vendor cannot agree on a payment plan, the hospital shall create a Reasonable Payment Plan, consisting of monthly payments that are not more than 10% of the patient's family's monthly income, excluding money spent on essential living expenses. Essential living expenses include rent on your home, other payments and maintenance of your house, food and household supplies, utilities, telephone, clothing, medical and dental payments, insurance, school, child care, child or spousal support, transportation and car expenses, including car insurance, gas, and repairs, installment payments, laundry and cleaning, and other everyday expenses. The patient will be asked to complete a Financial Assistance Application to help determine the Reasonable Payment Formula.
C. No Interest
  1. Any payment plan offered by the Hospital to assist patients receiving financial assistance shall by 100% interest-free.

III. Payment Limitations

A. The Hospital shall limit the amount it charges any patient at or below 350% of the FPG to the amount the Hospital would expect to receive for providing the relevant services from Medicare, Medi-Cal, the Healthy Families Program, or another government-sponsored health program of health benefits in California, whichever is greater.

B. The Hospital shall charge no more than the amount that it generally bills, or the "AGB," for any service that it provides to an individual eligible to participate in the FAP. The Hospital shall determine the AGB for a particular service by using the billing and coding process that it would use if the FAP-eligible individual were a Medicare fee-for service or Medicaid beneficiary, and setting the AGB for the relevant services at the amount that the Hospital determines would be the total amount that it would receive from Medicare or Medicaid, and the amount the patient would be personally responsible for paying in the form of co-payments, co-insurance, and deductibles.

IV. Declaring an Extended Payment Plan No Longer Operative

A. A hospital may declare a payment plan no longer operative if the patient fails to make all consecutive payments over a 90-day period.

B. Before declaring a payment plan no longer operative, the hospital, collection agency, or assignee shall make a reasonable attempt to contact the patient by telephone, and to provide them written notice, that the extended payment plan may become inoperative. This communication must also inform the patient that they can renegotiate the extended payment plan. The hospital and its collection agency and any assignee of the hospital or its collection agency are required to attempt to renegotiate the terms of the defaulted extended payment plan if the patient asks to do so. The written notice and telephone call must be made to the last known telephone number and address of the patient.

Fair Pricing - Uninsured Discount Policy

Purpose:

To standardize payment options to uninsured patients at Valley Presbyterian Hospital ("Hospital").

Policy:

It is the Hospital's policy to establish consistent operating protocols for uninsured patients. By establishing these protocols, the Hospital's overall objective is to expedite and maximize collection from uninsured patients who are unable to pay full billed charges.

Procedure:

I. The Patient Access Services (PAS) Department will identify the patient's ability to pay upon admission or registration.

A. If the patient does not have private insurance coverage, Medicare or Medi-Cal:
  1. The patient will be provided an estimate for the patient financial responsibility that will be due for the tests/procedures to be provided or, in the case of an inpatient admission, for the estimated length of stay based upon their primary diagnosis.
  2. If the patient is unable to pay the estimate in full or make payment arrangements, the patient will be referred to Financial Counseling for a Medi-Cal eligibility screening based on the patient's confidential financial information.
  3. If the patient does not meet criteria for Medi-Cal coverage and the patient is not eligible for our Charity program:

a. If still an inpatient, the patient will be referred back to a Financial Counselor for discussion on payment of the patient financial responsibility.

b. If the patient has been discharged the account is referred to a vendor handling early out accounts.

II. The estimate of the patient's financial responsibility is created and is a discounted price for services offered by the Hospital, which is standardized for all uninsured patients.

A. On an elective procedure or admission on an uninsured patient, a PAS representative will discuss the estimate for services withe the patient.

B. On emergency services or emergency admissions, uninsured patients receive an estimate for services after triage and medical screening by a physician are completed.

C. On an elective procedure, the payment must be collected prior to services or an accepted deposit and payment arrangements must be approved by management prior to the delivery of services.

D. If a patient is scheduled to have more than one outpatient surgical procedure in the Operating Room, and one or more of the procedures are not covered by the insurance, the insurance will be billed for the covered procedure(s). The patient will pay a flat fee of 850.00 for each additional hour, or portion thereof, required to complete the non-covered outpatient elective procedure. If implants are involved and are not provided by the physician, there will be an additional payment of implant cost plus 10%. The patient is expected to pay the estimated amount prior to the date of service.

E. The PAS representative will explain to the patient that the estimate is ONLY for hospital services and does not include professional fees such as Anesthesiology, Radiology, Pathology or Physicians or Surgeon's professional fee. This statement is also written on the estimate that is provided to the patient.