101 CMR, § 613.06

Current through Register 1538, January 3, 2025

Section 613.06 - Allowable Bad Debt

(1)General Requirements. Acute Hospitals may submit claims for Emergency Bad Debt as defined in 101 CMR 613.06(2). Acute Hospitals and Community Health Centers may submit claims for Bad Debt for Urgent Care Services as defined in 101 CMR 613.06(3) and (4). Providers may not submit a claim for a deductible or coinsurance portion of a claim for which an insured Patient or Low Income Patient is responsible. Providers may only submit claims for the services described in 101 CMR 613.03(2) through (4).

(a)Required Collection Action. Providers may submit claims for Bad Debt only after required collection action, including the following.

1.Collecting Patient Information.

a.Inpatient Services. An Acute Hospital must identify the department responsible for obtaining the information from the Patient, and make reasonable efforts to obtain the financial information necessary to determine responsibility for payment of the Acute Hospital bill from the Patient or Guarantor. If the Patient or Guarantor is unable to provide the information needed, and the Patient consents, an Acute Hospital must make reasonable efforts to contact the relatives, friends, and Guarantor and the Patient for additional information while the Patient is in the Acute Hospital. If an Acute Hospital has not obtained sufficient Patient financial information to assess the ability of the Patient or the Guarantor to pay for services prior to the date of discharge, the Acute Hospital must make reasonable efforts to obtain the necessary information at the time of the Patient's discharge.

b.Emergency Room, Outpatient Services, and Community Health Center Services. A Provider must make reasonable efforts, as soon as reasonably possible, to obtain the financial information necessary to determine responsibility for payment of the bill from the Patient or Guarantor.

2.Verification of Patient-supplied Information.

a.Inpatient. An Acute Hospital must make reasonable efforts to verify the Patient-supplied information prior to the Patient discharge. The verification may occur at any time during the provision of services, at the time of the Patient discharge, or during the collection process.

b.Acute Hospital Outpatient and Community Health Centers. A Provider must make reasonable efforts to verify Patient-supplied information at the time the Patient receives the services. The verification of Patient-supplied information may occur at the time the Patient receives the services or during the collection process.

3.Reasonable Collection Efforts.

a. A Provider must make the same effort to collect accounts for uninsured individuals as it does to collect accounts from any other Patient classifications.

b. The minimum requirements before writing off an account to the Health Safety Net include

i. an initial bill to the party responsible for the Patient's personal financial obligations;

ii. subsequent billings, telephone calls, collection letters, personal contact notices, computer notifications, and any other notification method that constitutes a genuine effort to contact the party responsible for the obligation;

iii. documentation of alternative efforts to locate the party responsible for the obligation or the correct address on billings returned by the postal office service as "incorrect address" or "undeliverable";

iv. sending a final notice by certified mail for balances over $1,000 where notices have not been returned as "incorrect address" or "undeliverable"; and

v. documentation of continuous Collection Action undertaken on a regular, frequent basis. When evaluating whether a Provider has engaged in continuous Collection Action, the Health Safety Net Office may use a gap in Collection Action of greater than 120 days as a guideline for noncompliance, but may use its discretion when determining whether a Provider has made a reasonable effort to meet the standard.

c. If, after reasonable attempts to collect a bill, the debt for Emergency Services for an uninsured individual remains unpaid after a period of 120 days of continuous Collection Action, the bill may be deemed uncollectible and billed to the Health Safety Net Office.

d. The Patient's file must include all documentation of the Provider's collection effort including copies of the bill(s), follow-up letters, reports of telephone and personal contact, and any other effort made.

(b)Reporting Requirements.

1.Claims Submission. Providers must submit claims in accordance with the requirements of 101 CMR 613.07. Acute Hospitals must submit a claim for each inpatient Bad Debt. Community Health Centers must submit a claim for each Bad Debt.

2.Additional Information. Providers must submit the following additional information for Community Health Center and Acute Hospital inpatient Bad Debt services in a form specified by the Health Safety Net Office. For outpatient services, Acute Hospitals and Hospital-licensed Health Centers must submit this information within 30 days of a request by the Health Safety Net Office.

Patient Identifiers:

Name

Address

Phone#

DOB

SSN#

TCN

Med Record*

MassHealth# (RID and/or RHN)

Date of Service

Total Charge for Services

Net Charge submitted to Health Safety Net

Evidence of Reasonable Collection Efforts:

Date of Initial Bill

Date of Second Bill

Date of Third Bill

Date of Fourth Bill

Date of Returned Mail

Date of Certified Letter for accounts over $1,000

Date of Initial Phone Contact

Date of Follow up Phone Contact

Dates of Other Efforts (other phone calls, letters to Patient, attorney or referral to collection agency)

Date Account was submitted to Health Safety Net Office

3. The Health Safety Net Office may deny payment for any claim for which required documentation is not submitted. If the Health Safety Net Office notifies a Provider that a claim will be denied due to insufficient documentation, the Provider must submit the required documentation within 30 days of the date of the notice that the claim will be denied.

(2)Acute Hospital Emergency Bad Debt Claims. An Acute Hospital may submit a claim for Emergency Bad Debt if

(a) the services were provided to

1. an uninsured individual who is not a Low Income Patient, unless the individual is a Dental-only Low Income Patient, and the Provider has verified through EVS that the individual has not submitted an Application; or

2. an uninsured individual whom the Acute Hospital assists in completing an Application and is determined to be a Low Income Patient or determined into a category exempt from collection action in accordance with 101 CMR 613.08(3). Bad Debt claims for these individuals are exempt from the requirements of 101 CMR 613.06(2)(c);

(b) the services provided were Emergency or Urgent Care Services;

(c) the Acute Hospital can document that it has undertaken the required Collection Action as defined in 101 CMR 613.06(l)(a) for the account; and

(d) the bill remains unpaid after a period of 120 days of continuous Collection Action.

(3)Hospital Licensed Health Center Bad Debt. An Acute Hospital or a Hospital Licensed Health Center may submit a claim for Bad Debt for Urgent Care Services if

(a) the services were provided at a Hospital Licensed Health Center;

(b) the services were provided to

1. an uninsured individual who is not a Low Income Patient, unless the individual is a Dental-only Low Income Patient. The Provider may not submit a claim for a deductible or the coinsurance portion of a claim for which an insured Patient is responsible. The Provider may not submit a claim unless it has checked EVS to determine if the Patient has filed an Application; or

2. an uninsured individual whom the Provider assists in completing an Application is determined into a category exempt from Collection Action in accordance with 101 CMR 613.08(3). Bad Debt claims for these individuals are exempt from the requirements of 101 CMR 613.06(3)(e);

(c) the Provider provided Urgent Care Services as defined in 101 CMR 613.02 to the Patient. A Provider may submit a claim for all Eligible Services provided during the Urgent Care Services visit, including Ancillary Services provided on site;

(d) the responsible physician determined that the Patient required Urgent Care Services. A Provider may submit a claim for Urgent Care Services, but not for other services provided to Patients determined not to require Urgent Care Services;

(e) the Provider undertook the required Collection Action as defined in 101 CMR 613.06(1)(a) and submitted the information required in 101 CMR 613.06(1)(b) for the account; and

(f) the bill remains unpaid after a period of 120 days of continuous Collection Action.

(4)Community Health Center Bad Debt. A Community Health Center may submit a claim for Bad Debt for Urgent Care Services if

(a) the services were provided to

(b) the Provider provided Urgent Care Services as defined in 101 CMR 613.02 to the Patient. A Provider may submit a claim for all Eligible Services provided during the Urgent Care Services visit, including Ancillary Services provided on site;

(c) the responsible physician determined that the Patient required Urgent Care Services. A Provider may submit a claim for Urgent Care Services, but not for other services provided to Patients determined not to require Urgent Care Services;

(d) the Provider undertook the required Collection Action as defined in 101 CMR 613.06(1)(a) and submitted the information required in 101 CMR 613.06(1)(b) for the account; and

(e) the bill remains unpaid after a period of 120 days of continuous Collection Action.

(5)Department of Revenue Intercept. The Health Safety Net Office initiates a match with the Massachusetts Department of Revenue for individuals for whom a Provider has submitted a claim for Bad Debt. The Health Safety Net Office may request that the Department of Revenue intercept payments to the individual up to an amount equal to the amount paid to the Provider for the Services.