Financial Assistance Policy

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McKenzie Medical Center – McKenzie

PURPOSE: We are committed to making comprehensive primary care services available and accessible to uninsured and underinsured patients by establishing fees that are affordable to them and in accordance with federal regulations.  McKenzie Medical Center will provide, without discrimination, medically necessary care regardless of their inability to pay; whether the source of payment would be made with Medicare, Medicaid, or CHIP; the individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity.

POLICY:  We offer a Financial Assistance Program based on a sliding fee schedule.  A Financial Hardship/Indigent policy will be provided to eligible individuals on the basis of their income and family size.  Only individuals living in households with income at or below 200% of the Federal Poverty Level will qualify for this policy.  Notice of this program will be posted in our clinic as well as on our website.

RESPONSIBILITY:  Patient Services Representatives and Business Office Manager


Amount Generally Billed:  The Amount Generally Billed (AGB) for emergency and other medically necessary services shall be calculated yearly based on a look-back method approved by the Internal Revenue Services.  The AGB will be calculated by including all past claims from the prior 12-month period that have been paid in full to the hospital facility for medically necessary care by Medicare fee-for-service together with all private health insurers paying claims.  This can include coinsurance; copayments and deductibles.  The AGB for emergency or medically necessary care provided to a financial assistance eligible individual is determined by multiplying gross charges for that care by the percentage of gross charges (called AGB Percentage).  The AGB percentage is calculated at least annually by dividing the sum of certain claims paid to the hospital facility by the sum of the associated gross charges for those claims.

Emergency/Medically Necessary Services: Emergency or other health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine. Some examples of nonmedically necessary services are experimental or non-traditional care, tests, or treatment, gastric by-pass procedures, retail services such as eye wear or contact lenses, elective services, cosmetic, birth control, transportation, food, durable medical equipment, circumcision and prescriptions.

Family Size:  Using the Census Bureau definition, a group of two or more people who live together and who are related by birth, marriage, or adoption.  According to Internal Revenue Service rules, if the patient claims someone as a dependent on their income tax return, they may be considered a dependent for purposes of the Financial Assistance Policy.

Financial Assistance:  When McKenzie Medical Center-McKenzie qualifies a patient for financial assistance based on income and family size, it conditionally suspends its legal right to demand full compensation for outstanding charges due from the patient.  Full compensation means the amount of money McKenzie Medical Center-McKenzie would have received for services if no discounts had been applied. 

Financial Assistance Application Period:  The application time period patients may apply for financial assistance discounts is_15_days from the first billing statement. Accounts beyond this _30_ day application period are not eligible for a financial assistance discount unless there are special circumstances that warrant an exception and are approved by management.

Income:  Household Income is determined using the Census Bureau definition, which uses the following income sources:

  • Earnings/wages, unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources;
  • Noncash benefits (such as food stamps and housing subsidies) do not count;
  • Determined on a before-tax basis;
  • Excludes capital gains or losses; and
  • If a person lives with a family, includes the income of all family members who live together as part of a single-family unit.  A roomer or boarder is not included.

PM:  Practice Management (Sevocity)

Underinsured:  The patient has some level of insurance or third-party assistance but still has out-of-pocket expenses that exceed his/her financial abilities.

Uninsured:  The patient has no level of insurance or third-party assistance to assist with meeting his/her payment obligations.


  1. As part of the registration process, the front office clerk will determine whether the applicant is covered under a health insurance plan.  If the applicant is uninsured or underinsured, he/she has the availability of the Financial Hardship/Indigent Policy and the clerk will explain the paperwork needed to complete the application.
  2. Individuals interested in applying for the discount must provide one of the following forms of written verification of household income and size:
    1. Self-Declaration of Income (to be used only if the applicant does not have a written income verification) (Refer to Self-Declaration Form)
    1. Last two paycheck statements or latest tax return.
  3. Once the applicant completes the Application, the Patient Account Office will review it for completeness.
  4. The Patient Account Office will make a copy of the written income verification and attach it to the registration form.
  5. If the person does not have written income verification, ask the applicant to complete the income and family self-declaration (Refer to Self-Declaration Form)
  6. The Patient Accounts Office will seek supervisor approval for the Self-Declaration.  Once the application is approved, inform the applicant of the temporary discounted granted and expected amount to be paid.  See Attachment A for Sliding Fee Schedule.
    1. Patient Accounts Office will change the account type to Financial Hardship and a pop-up is placed in PM.
    1. Check in will read the popup and refer to “Notes” for details.  Their appointment status symbol will be a yellow dot meaning “exception”.  Be sure to document “Hardship” on the encounter and highlight for billing purposes.
    1. These patients will be seen with an orange folder during visits.  If the patient is here for an elective service ONLY, then they will be in their usual color folder (manilla, blue, or red).
  7. Financial Assistance eligibility is reviewed every __6__ months/annually.
  8. If the patient balance is over $200, and the patient desires to pay in full, a ten percent discount is offered.
  9. Every three years MMC will evaluate the SFS Discount Program. Each patient balance will be reviewed on a case by case basis.

Approved:_________________________________________ Date:_________________________             

Date of Board Approval:________________________

Office Use Only

I witness that this client has no documentation for proof of income:


Date:       ________________________________________________                                                     

Attachment A:  Sliding Fee Schedule