User Guide — Sliding Fee

 

Your practice must have the Sliding Fee Programs feature enabled. In addition, your practice must have the Post-Adjudication Sliding Fee Plans feature enabled to perform these tasks:

• Add a poverty-based sliding fee program
• Add a poverty-based sliding fee plan
• View the Health & Human Services (HHS) poverty guidelines table
• Apply a poverty-based sliding fee plan to a patient
• Edit a patient's existing poverty-based sliding fee plan
• Adjust sliding fee plan balances automatically after primary and/or secondary payer adjudication

To access the Sliding Fee Programs, Non-Poverty-Based Sliding Fee Plans, and Poverty-Based Sliding Fee Plans pages, you must have the Practice Set-Up: Sliding Fee Programs/ Plans permission.

 

You can enable sliding scale fee plans for self-pay patients. Sliding scale fee plans designate a flat fee, percentage, or a combination flat fee-and-percentage charge for billed services.

 

Most free-care programs require participating providers to provide reports on the services provided to a certain population of patients. The creation of sliding fee programs and plans allows you to run financial reports with patient, service, charge, and payment information. Sliding fee plans are a great way to account for time-of-service discounts or adjustments for self-pay patients; the athenaOne native reporting capabilities allow you to analyze these discount programs.

 

For example: Dr. Smith of ABC Medical Associates participates in a free-care program sponsored by her community hospital. Every other week, the office operates a clinic where certain patients receive urgent and preventive care services. Patients pay 20% of the total charge for rendered services. The practice receives an additional reimbursement from the hospital every month and must provide reports detailing the names of patients, the billed procedures, and the charge amounts. The practice manager has a sliding fee program called "Hospital Free Care" under which there is a "20% Clinic" sliding fee plan.

 

The Sliding Fee feature has two versions:

• With the Basic Sliding Fee feature, when a new claim is created for the patient, athenaOne creates an adjustment and transfers the discounted amount to the patient automatically.
• With the Post-Adjudication Sliding Fees feature, athenaOne makes the adjustment after the balance is transferred to the patient.

Sliding scale plans can be either poverty-based or non-poverty-based.

Important: athenahealth recommends that you create separate programs for poverty-based and non-poverty-based plans. A single sliding fee program should not contain both types of plans.

 

When using the Sliding Fee feature, your practice should evaluate all relevant legal obligations, including payer contracts and Medicare guidelines. It is the responsibility of your practice to ensure that you are in compliance with state and federal regulations regarding fee schedules. By law, your practice must represent all charges accurately, including those charged on a sliding fee scale.

 

 

With Post-Adjudication Sliding Fee Plans, you can exclude services from sliding scale billing using these parameters:

• Service department
• Rendering provider
• Procedure code group
• Procedure code modifier
• Procedure code

If a procedure in a sliding fee plan meets any of the parameters you set, that procedure will not be billed on a sliding scale.

 

 

The high-level steps for configuring sliding scale payments are as follows.

1. Use the Sliding Fee Programs page to define a program. The sliding scale fee program is designed to provide a general grouping for payment plans. For example, you can create a "Ryan White" sliding scale fee program, and within that program, you can define several different plans, each with a different percentage or flat fee to specify the patient responsibility.
2. Use the Non-Poverty-Based Sliding Fee Plans or Poverty-Based Sliding Fee Plans page to create a plan that specifies the level of patient responsibility. You can create various plans within one sliding fee program. Each plan has its own levels of patient responsibility.
3. After the program and plans are defined, you can select the desired sliding scale plan in lieu of a primary insurance. When a new claim is created for the patient, athenaOne automatically creates an adjustment and transfers the remaining amount to the patient's outstanding balance.

 

You can create poverty-based sliding fee programs and plans by entering a range in the Poverty level range field on the Poverty-Based Sliding Fee Plans page.

• A poverty-based program is a sliding fee program with at least one poverty-based plan assigned to it.
• A poverty-based plan is a sliding fee plan that has a date range specified in the Poverty level range field.

Creating a poverty-based sliding fee program and plans

Follow these steps to create a poverty-based sliding fee program and plans.

1. Create a sliding fee program to use for poverty-based plans (see Sliding Fee Programs). Make sure that the program name clearly indicates that the program is poverty-based. athenahealth recommends that all the plans within the program be poverty-based.
2. Create the plans using the Poverty-Based Sliding Fee Plans page. When you enter a range in the Poverty level range field, the plan becomes a poverty-based plan when the plan is saved. You can create as many poverty-based plans as you need.
   Note: When a program has at least one poverty-based plan assigned to it, athenaOne considers the program to be poverty-based, so the poverty-level table link appears when you select the program from the Sliding fee program filter on the Non-Poverty-Based Sliding Fee Plans page.
3. After you create the complete set of poverty-based plans, verify that there are no gaps in the poverty level ranges. You can do this from the Poverty-Based Sliding Fee Plans page. Click the Poverty Bounds column to sort the table by range, look for any gaps, and update your plans if needed.

Placing a patient on a poverty-based plan

When you place a patient on a poverty-based payment plan (by selecting a poverty-based program on the Add Cash Policy Details page), athenaOne selects the correct plan based on the patient's family size and income. On the Add Cash Policy Details page, enter the family income in the Income field, and then click Calculate plan to populate the Sliding fee plan. athenaOne selects the correct poverty-based plan for you automatically, based on the data you entered in the Family size and Income fields, according to the most recently uploaded Health & Human Services (HHS) Poverty Guidelines.

 

You can view the most recent Health & Human Services (HHS) Poverty Guidelines right from the Poverty-Based Sliding Fee Plans page.

 

 

The sliding fee programs and plans are available in the advanced view of the Accounts Receivable Aging Wizard and the Activity Wizard. Select the appropriate program from the list and then click the Sliding Fee Plans checkbox to receive a breakdown of the individual plans.

 

You can report on sliding fee plans at the charge level using the Report Builder. We add the following fields as display columns and filters to the Transaction Activity report type on the Report Builder page:

• Sliding Fee Created By
• Sliding Fee Created Date
• Sliding Fee Expiration Date
• Sliding Fee Issue Date
• Sliding Fee Notes
• Sliding Fee Plan Name
• Sliding Fee Program Name

You can also use these fields for the Claim report type.

 

The "Patient Outstanding" field is a display column for the Patient Demographics report type. This field displays an individual patient's outstanding amount, as opposed to the Measure field "Sum of Patient Outstanding Amount," which sums patient outstanding amounts for all the patients in a given row. To see individual patient outstanding amounts, use the "Patient Outstanding" field to avoid the possibility of double-counting patients.