SRMC Guide to Patient Billing PFS Guide to...SRMC collect co-pays, coinsurance, deductible, or a...

About SRMC Sidney Regional Medical Center is a critical access hospital

offering a wide array of services including a 25-bed Acute

Care, Critical Care unit, 24-hour provider covered Emergency

Room, Physicians Clinic, Walk-in Clinic, Surgical services,

Home Health and Hospice, Extended Care Unit, Assisted

Living facility and much more. SRMC serves a seven-county

area in the southern Nebraska Panhandle. SRMC and its

partners provide many services not traditionally found in a

rural community.

Mission

To revolutionize healthcare services.

Vision

To be the healthcare center of choice.

Value

Do the right thing. Make a difference.

Our Team

SRMC employees more than 390 people including

approximately 70 volunteers. Our medical staff includes 4

family practice physicians, 2 general surgeons, a urologist,

hospitalists, 10 certified physician assistants and almost 20

visiting providers specializing in areas such as ENT,

cardiology, gastroenterology, orthopedic surgery, pain

management and podiatry.

Sidney Regional Medical Center complies with applicable Federal civil rights laws and does not dis-criminate on the basis of race, color, national origin, age, disability, or sex. This institution is an equal

opportunity employer and provider. 1000 Pole Creek Crossing ∙ Sidney NE 69162 308.254.5825 ∙ www.SidneyRMC.com

Doing the right thing! Making a difference!

Pat ient Financ ia l Serv ices

SRMC Guide to

Patient Billing

Note from the CEO

The cost of healthcare is certainly a hot topic.

At SRMC, our mission is to ’revolutionize healthcare

services’ and we take this mission to heart with every

patient we care for.

Our mission supports our team’s vision, ‘to be the

healthcare system of choice.’ With this in mind, we also

have a value statement and that says ‘do the right

thing, make a difference.

All this stated, we understand how complex healthcare

and the billing for services is and how confusing it can

be. This guide is designed to truly promote transparen-

cy and be a helpful tool when planning your next visit or

preparing for a procedure. We hope you will find it use-

ful. As well we also have several tools available online

including the website, www.SidneyRMC.com and our

SidneyRMC app FREE in the App store and Google

Play.

We know you have choices in healthcare we want to

make sure you have everything you need when decid-

ing where to go and how to pay for your healthcare

needs.

Sincerely,

Jason Petik, CEO

NONDISCRIMINATION AND ACCESSIBILITY REQUIREMENTS AND NONDISCRIMINATION

STATEMENT:

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धधध KURDISH قەسە دەکەيت، خزمەتگوزاريەکانی يارمەتی زمان، بەخۆڕايی، بۆ تۆ بەردەستە. پەيوەندی بە کوردی ئاگاداری: ئەگەر بە زمانی بکە 800.752.6096FARSI: . تماس بگيريد 800.752.6096: اگر بە زبان فارسی گفتگو می کنيد، تسهيالت زبانی بصورت رايگان برای شما فراهم می باشد. با توجه JAPANESE: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。800.752.6096 まで、お電話にてご連絡く

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Sidney Regional Medical Center (SRMC) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Sidney Regional Medical Center does not exclude people or treat

them differently because of race, color, national origin, age, disability, or sex.

Sidney Regional Medical Center:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services, contact Language Line at 800.752.6096, option 1, 24 hours a day, daily.

If you believe that Sidney Regional Medical Center has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Compliance Officer, Sidney Regional Medical Center, 308.254.5825 ext. 1440, fax 308.254.8080. You can file a grievance in person or by mail or fax. If

you need help filing a grievance, the Compliance Officer is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights,

electronically through the Office for Civil Rights Complaint Portal, available at

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

800.368.1019, 800.537.7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/filing-with-ocr/index.html.

800.752.6096.

800.752.6096.

800.752.6096.

800.752.6096.

4

Notes:

Sidney Regional Medical Center Page 3

Table of contents

Introduction 4

Glossary 5-6

Billing process 7-9

Pre-service estimates 10

Payment options 11-13

Guarantor statements 14-16

Guarantor letters 17-18

Charity Care 19-20

Bills will you receive 21

Payment options 22

In-network insurance 23

Coordination of Benefits 24

Office Visit Charges 25

Wellness and annual exams 26

School/athletic physicals 27

Self-administered medication 27

FAQ’s 28-33

About SRMC 33

Sidney Regional Medical Center

Introduction

Patient Financial Services—Here to provide patients with

the tools and resources to understand insurance

coverage and manage medical expenses in a caring,

honest and confidential manner because your financial

well-being is important too.

Thank you for choosing SRMC for your health care

needs. Insurance and paying for medical expenses can

be overwhelming and confusing. SRMC is committed to

making this experience a positive one.

In addition to the monthly premiums, most insurance

policies require patients to pay a portion of the medical

expenses in the form of co-pays, coinsurance or

deductibles, or any combination of these.

Insurance companies have set the expectation that

SRMC collect co-pays, coinsurance, deductible, or a

combination of those from patients. To help manage this

expense and eliminate any surprises after services,

SRMC takes a proactive approach in providing an

estimate and payment arrangements prior to or at the

time of service.


Contact Patient Financial Services at 308.254.8778 with questions. 1000 Pole Creek Crossing ∙ Sidney NE 69162 ∙ 308.254.5825 ∙ www.SidneyRMC.com

Page 33

FAQs (cont.)

account to be referred to an external collection agency. Payment in full or payment plans must be established prior to the time of service on all non-emergent services.

Q. WHAT IS THE PHONE NUMBER OF THE COLLECTION

AGENCY MY ACCOUNT WAS SENT TO?

A. SRMC uses two collection agencies. If the guarantor’s last name begins with A-M, please contact Panhandle Collections at 308-632-5210. If the guarantor’s last name begins with N-Z, please contact Credit Management Services at 308-382-3000.

FAQ Patient Resources

Q. WHY DO YOU NEED TO SEE MY INSURANCE CARDS

EVERY TIME I HAVE AN APPOINTMENT?

A. To ensure your claim is processed as efficiently as possible. When we verify we have the most current card and billing address on file, we can reduce potential delays during the claim process caused by records not matching.

Q. WHAT INFORMATION DO I NEED TO BRING WITH ME TO

THE HOSPITAL?

A. Patients should bring the following information when registering:

Insurance Card/Medicare/Medicaid card Driver’s license Co-pay or deductible Worker’s compensation information (if applicable) Auto coverage and claim information for auto accident (if

applicable)

Q. IF I NEED MEDICAL ATTENTION BUT CAN NOT AFFORD

TO PAY FOR IT, WHAT CAN I DO?

A. No one is turned away from SRMC needing emergent/emergency care because of inability to pay. We direct patients to a Patient Account Specialist the Financial Counselors located in the Patient Financial Department who will work with you to develop a


FAQs (cont.)

Typically, a patient will receive multiple EOB’s for one service as insurance pays the facility charges (supplies, room, medications, labs, radiology tests) separately from the fees charged by the physicians or other providers.

Q. HOW ARE YOUR PRICES DETERMINED?

A. The Nebraska Hospital Association hospital guide is used to compare pricing with other facilities in Nebraska. Prices are also determined by reviewing what insurance companies will allow for services.

Q. HOW ARE CHARGES DETERMINED?

A. Charges are based on the type and level of service received. Physicians document details of the service provided. Charges are based on that documentation.

Q. I CAME IN FOR MY ANNUAL WELLNESS EXAM BUT MY INSURANCE COMPANY IS NOT PAYING FOR IT BECAUSE IT

WAS NOT “CODED” AS A WELLNESS EXAM?

A. At a wellness/annual visit the insurance company pays for the provider to assess the patient’s health and for certain screenings for any undiagnosed issues. If the patient discusses any prior or current ailments, the visit may no longer be considered a physical. It will then be coded and billed as an office visit and any applicable co-pays, deductible or co-insurance will be due from the guarantor. If the patient has other ailments needing to be discussed or the patient becomes ill prior to this physical, a separate visit will be necessary.

Q. WILL SRMC PRE-CERTIFY SERVICES OR DO I?

A. Although there are some services that SRMC will pre-certify, it is best for the guarantor to contact their insurance for pre-certification as well.

Q. HOW DO I AVOID COLLECTION ACTIVITY?

A. Delays in full payment or failure to establish a payment plan that meets minimum guidelines for the amount due may cause this

Glossary

The following terms are frequently used when discussing

medical billing, insurance and patient financial

responsibilities for healthcare services.

Co-insurance

The percentage set by your insurance company that

you pay for services after you have paid the total

annual deductible amount.

Co-pay

A co-pay is the amount specified by your insurance

company to be paid for each office visit with a doctor.

Some plans also have co-pays for other services such

as Physical Therapy and ER Visits. Your co-pay

amount may be listed on your insurance card.

Contractual Adjustment

This is the discount that is given on services based on

the contract SRMC has with your insurance company.

Deductible

The annual amount set by your insurance company

that must be paid by you before insurance pays for

services, and before co-insurance applies to your

services.

Explanation of Benefits (EOB)

This is the paperwork you receive from your insurance

company showing what they paid and what they have

determined is your responsibility to pay, per your

coverage. This amount should match the statement

you receive from Sidney Regional Medical Center.

Typically, a patient will receive multiple EOB’s for one

service as insurance pays the facility charges

(supplies, room, medications, labs, radiology tests)

separately from the fees charged by the physicians or

other providers.

Out of Pocket (OOP)

This is the most you will pay during a policy period

(typically one year) before your insurance starts to pay

100% for covered services. This amount generally

consists of the full amount you have paid for

deductibles, co-insurance and co-payments. There are

exceptions to what some plans apply to OOP.

Premium

This is the amount you pay your insurance company to

obtain coverage. It is typically paid monthly or per

paycheck. If your employer provides insurance, this

amount often comes directly out of your paycheck. If a

premium is not paid, insurance coverage lapses and is

no longer valid after the grace period.

The billing process begins the day services are

received.


Glossary (cont.)


Page 31

Q. WHAT IS THE MINIMUM PAYMENT I CAN MAKE?

A. The minimum payment will be different for each account and is based upon the total amount of your outstanding balance.

Q. WHY DO I NEED TO ESTABLISH AN OFFICAL PAYMENT

PLAN?

A. By agreeing to an interest free, no fee, no penalty payment plan, we keep your account internally and keep it from aging out to an outside source, who would charge interest. If you are unable to pay your balance, SRMC has payment options available.

Q. DO YOU HAVE FINANCIAL ASSISTANCE?

A. Yes. We do offer charity care for those who qualify. Qualification is based upon federal poverty guidelines, equity and assets of the patient, along with other criteria. Complete an application here.

Q. WHY ARE FAMILY VISITS NOT LISTED ON ONE

STATEMENT UNDER ONE ACCOUNT NUMBER?

A. Statements are generated per guarantor. The guarantor is the person who signed the consent form at the time of admissions, as this person is signing for services and to be responsible for any payment that is due.

Q. HOW CAN I GET ALL FAMILY VISITS ON ONE STATEMENT?

Contact the SRMC Patient Financial Services at 308.254.8778, Monday – Thursday 8am-5pm and Friday, from 8am - 4pm.

Q. HOW DO I RECEIVE AN ITEMIZED STATEMENT?

A. To request an itemized statement, email our team at: [email protected] or call us at 308.254.8778 Monday – Thursday 8am-5pm and Friday, from 8am - 4pm.

Q. WHAT IS AN EOB (Explanation of Benefits)?

A. This is the paperwork you receive from your insurance company showing what they paid and what they have determined is your responsibility to pay, per your coverage. This amount should match the statement you receive from Sidney Regional Medical Center.

FAQs (cont.)


FAQs (cont.)

Q. CAN I GET A DISCOUNT ON MY BILL?

A. Yes, if you do not have insurance or you had a service that your insurance does not cover, you could be eligible for a discount if you pay in full within 45 days from the date of service. The discount will be applied to your account upon receipt of payment in full.

Q. I HAVE INSURANCE WHY DID I RECEIVE A BILL?

A. This is the amount that your insurance company left due to the guarantor. Typically this amount is for co-pays, deductibles, co-insurance or for a service the insurance company does not cover under your policy. You should have received an EOB(s) from your insurance company that matches what SRMC has billed you

Q. WHO SHOULD I CALL IF I BELIEVE THAT THE CHARGES

ON MY BILL ARE INCORRECT?

A. If you have any concerns regarding your bill, please call 308.254.8778 we would be delighted to answer any questions you might have about your bill.

Q. I HAVE MEDICARE AND SUPPLEMENTAL INSURANCE.

WHY DO I OWE A BALANCE?

A. Unfortunately, Medicare does not cover oral or self-administered medications given in an outpatient setting at the hospital. An outpatient setting at Sidney Regional Medical Center would include: 1) a visit in the ER, 2) being admitted for observation or 3) outpatient surgeries.

Q. DO YOU HAVE PAYMENT PLANS AVAILABLE?

A. Yes, we have payment plans available. You may be eligible to establish a monthly payment plan. Please call 308.254.8778 to find out what payment plans are available for your balance due.

Billing process

Insured patients

Generally, within 4-6 weeks of the visit, patients should

receive an explanation of benefits (EOB) from the

insurance company. Shortly thereafter, patients will

receive a statement from SRMC. Patients should

compare the EOB to the "Patient Responsibility Due"

portion of the SRMC account statement. The balance

owed according to the EOB and the balance owed

according to the SRMC statement should equal. If they

are different, please contact Patient Financial Services.

In some cases, insurance companies may delay

processing of claims. Patients will receive information

from the insurance company regarding the delay.

If insurance doesn’t pay, SRMC will send a statement

showing patient amount due if insurance either doesn’t

pay for the service or leaves a remaining balance due

as patient responsibility.

Non-covered services

Non-covered services means that the patient’s contract

with the insurance company didn’t include coverage for

the services. For questions regarding coverage, contact

the insurance company to discuss coverage limits or to

add services to the contract.

Multiple claims on one visit

For most payers, SRMC is required to bill professional

fees and facility fees separately. A statement from

SRMC is not sent to the patient until insurance pays on

each one, which can cause a delay in patient receiving

the first statement from SRMC.

Facility fees are for the service or procedure being

provided.

Professional fees are for the doctors, physician

assistants and anesthesiologists.

Multiple insurance

coverage

If a patient has more than

one insurance, this may

also cause a delay as all

claims must be processed


Billing process (cont.)


Page 29

FAQs (cont.)

Q. WHAT COULD DELAY MY BILL?

A. Insurance companies requesting additional information from SRMC or from the patient in regards to your services. Please read all communication you get from your insurance company. If you fail to meet their request for information you could get end up paying for services that your insurance company should be paying.

Q. HOW CAN I MAKE A PAYMENT?

A. We accept the following forms of payment: Cash, Check, Credit Card/Debit(MasterCard, Visa, American Express,

Discover), Money Orders and cashier checks and have the following payment options:

Pay Online: www.SidneyRMC.com

select “Pay Online” Pay by phone: Call us at 308.254.8778 Mail your payment to: SRMC Attn: PFS Dept 1000 Pole Creek Crossing Sidney, NE 69162-1714 Stop by Patient Financial Services: 1000 Pole Creek Crossing Sidney, NE 69162

Monday - Thursday 8am - 5pm

Friday 8am - 4pm

FAQs


Q. WHEN WILL I RECEIVE MY BILL?

A. If you have insurance, and you provided our office with a current insurance card, our first step is to bill your insurance company. After the insurance company has processed claim(s), you will receive a bill with any unpaid portion that is due. This process usually takes an average of 30-60 days. If you have a secondary insurance or have multiple claims on one account this process can take longer. If you do not have insurance, you will receive a bill on the first date we send out statements, following your visit. Statements are sent out every 28 days.

Q. HOW MANY BILLS WILL I RECEIVE?

A. For most visits you will receive one bill from SRMC for

services received at our facility. An additional bill may be

received for the following:

Some visiting physicians bill their own professional fees,

these bills will come from the specific office of that provider.

Radiology services - an additional bill will be sent from

Advanced Medical Imaging Consultants (AMIC) for the

radiologist reading fee.

Cardiac event monitors (14 to 30 day monitors) – a bill from

Life Watch for the rental fee of the monitor.

Patients may receive a bill from University of Nebraska

Medical Center, Healthtronics, Prometheus or Liposcience

for some lab work.

Sleep Studies - an additional bill will be sent from Dr. Imes

office, the polysomnographer doctor, for interpretation/

reading of your study.


Pre-service estimates

Billing process (cont.)

by both the primary payer and the secondary payer

prior to a statement being sent

Liability claims in litigation

SRMC will file liability claims or accident and injury

claims with the liable party and or with the patient’s

insurance. If these claims are not paid by the billed

parties and end up in litigation between parties, these

claims will become the patient’s responsibility,

otherwise known as “private pay.”

Private pay patients

Patients that are not covered by insurance are known

as “true private pay” patients. Statements for services

at SRMC will be received approximately 30 – 45 days

from the date of service. Balances paid in full within 45

days of date of service, may be eligible for a “true

private pay” discount.

SRMC provides estimates either prior to scheduled

hospital services or at the time of service for clinic and

unscheduled visits at admissions. At this time payment

options are discussed and payment arrangements are

made.

SRMC utilizes software which produces cost estimates

based on customary/standard charges. It retrieves

patient-specific insurance information from the patient’s

insurance plan to provide an estimate of both the total

cost of services and what insurance expects the patient

to pay for hospital services.


Pre-service estimates (cont.)

Deductible and co-insurance on clinic visits is based on

the cost of an average level office visit. The office visit

level may change depending on how it is documented.

Please refer to page 25. Any unknown lab work or

other procedure that may occur during your visit will be

billed to the patient after insurance has been billed.

This estimate is for routine and usual charges for the

services, exams or procedures requested. The

information provided is a best estimate based on

the information selected and is not a guarantee of

what you will be charged. Please understand that in

many cases it is impossible to predict the final charges

as there are many variables involved in actual services

such as: the length of time spent in surgery or recovery,

specific equipment, supplies, and medications required,

additional tests required by your physician, and/or any

unusual special care or unexpected conditions or

complications.

If you have insurance, your benefits will ultimately

determine the amount you owe. Not all services are

covered by all insurance policies. To check your

coverage, contact your insurance.

Some insurances will cover an annual wellness visit at no

cost to the patient. If the child has not had an annual exam

within the last 365 days, this service can be provided as their

annual wellness visits as it meets and exceeds the

requirements of a school physical. This will ensure the child

receives the best care at the lowest cost to the guarantor.

Check with the insurance company to verify the plan has

wellness coverage before scheduling a visit, as coverage

varies by policy.

Page 27

School and athletic physicals

Medicare publishes a list of drugs they considered to be “self

-administered drugs”. This does not mean that you actually

took the medication on your own while you were in the

hospital but it is a medication that Medicare considers the

patient could take on their own outside of a hospital setting.

If a patient receives self-administered drugs not covered by

Medicare Part B, the hospital will bill the patient. These

drugs may be covered for anyone enrolled in a Medicare

drug plan (Part D). The patient is then responsible to pay for

the drug and/or submit a claim to Medicare for a refund.

Most hospital

pharmacies don’t

participate in Part D.

If a bill is received,

follow the directions in

the Medicare drug

plan’s enrollment

materials on submitting

an out-of-network claim.

Self-administered medications



Please be advised that preventative visits are limited

according to insurance company guidelines. Problem based

issues cannot be discussed at a wellness/annual visit.

At a wellness/annual visit the insurance company pays for

the provider to assess the patient’s health and for certain

screenings for any undiagnosed issues. If the patient

discusses any prior or current ailments, the visit may no

longer be considered a wellness/annual. It will then be

coded and billed as an office visit and any applicable co-

pays, deductible or co-insurance will be due from the

patient. If the patient has other ailments needing to be

discussed or the patient becomes ill prior to this wellness/

annual, a separate visit will be required.

SRMC providers are more than happy to review patient

issues, but a separate visit must be billed according to

standard wellness billing guidelines.

It is important to review the individual policy regarding the

insurance company’s preventative schedule as these vary

by insurance. For questions concerning insurance coverage

contact the company’s human resources department or

insurance supplier for more information.

Wellness and annual exams

Page 26 Sidney Regional Medical Center

The price of healthcare continues to be costly. In addition

to the monthly premiums, most insurance policies require

patients to pay a portion of the medical expenses in the

form of co-pays, coinsurance or deductibles, or any

combination of these.

Complete understanding of your insurance coverage is

essential when preparing for your next procedure or visit.

This allows you to effectively manage the financial aspect

of your care. We encourage you to establish your payment

arrangements prior to your visit. We understand

emergencies happen and we will work with you to create a

plan that works best. Our team will process your account

with insurance as timely as possibly, in the instance your

insurance does not pay SRMC timely, you may become

responsible for the bill.

Contact Patient Financial Services at 308.254.8778 with questions.

1000 Pole Creek Crossing ∙ Sidney NE 69162 ∙ 308.254.5825 ∙ www.SidneyRMC.com

Payments options

We would like to allow you as much time as possible to pay

your bill. The sooner you establish a payment option with

SRMC, the smaller your payments will be as they can be

spread out over a a longer period of time.

Payment in full—for your convenience we accept cash, check, money order, and all major credit cards.

Auto-pay/Recurring interest Free payments: Up to 8 months interest-free Auto pay from banking, Flex or credit card Weekly, bi-monthly payments options available Minimum monthly payment amount is $25, on accounts

under $200.

SRMC Care Solution - A convenient extended payment

option.

Auto Pay from Banking, Flex or Credit Card Electronic Statements 4.58% Interest Interest free if paid off within 6 months Up to 60 Months

Payments options (con’t)


Payment option established: Monthly

payments

At the time of service 8

Within 30 days of service date 7

Within 60 days of service date 6

Upon receipt of (after insurance processes):

1st statement 5

2nd statement 4

3rd statement 3

1st collection letter 2

2nd collection letter 1


Page 25

Office visit charges

Office

Visit

Level

Description of what estimates are based on

99212 · Minimal - Straight forward medical decision making

· Self limited or minor problems requiring counseling

99213

· Simple – One problem visit. Low complexity of medical

decision making

· Low to moderate problems requiring counseling or

coordination of care

99214

· Moderate - may be one problem or multiple, may also be a

new problem as well as workup (labs, x-rays ordered

prescription ordered).

· Moderate complexity of medical decision making.

· Moderate to High problems requiring counseling or


99215

· High - very detailed exam with multiple problems and/or

workup.

· Greater than 30 minutes spent with provider medical

decision making of moderate complexity.

· Moderate to High problems requiring counseling or


· Complex medical problem(s) requiring comprehensive

evaluation.

These office visits are based on being an established patient

or a patient not being seen for the first time by a doctor.

Prices are for the cost of the office visit only. This does not

include any additional procedure, lab work or radiology that

may occur.

Coordination of Benefits

Coordination of Benefits allows plans that provide health or

prescription coverage for a person with Medicare to

determine payment responsibilities.

Are there dependents on the insurance plan?

Does the patient have multiple insurance coverages?

Is the patient a dependent on a spouse’s plan and has

their own coverage?

Are children covered by two or more plans?

If so, we need your help to ensure your insurance company

pays for your services.

In order to ensure payment by the insurance company and

to prevent claim denials made in error, it’s important the

guarantor and/or patient contact the insurance company to

update the Coordination of Benefits (COB). This update is

typically required by the insurer on an annual basis. This is

also important if there have been any significant changes to

the guarantor’s and/or patient’s family (marriage, divorce,

new child, addition of step-children, etc.).

Refer to the back of the insurance card to find contact

information for customer service and contact them to

coordinate benefits.



External Loan Option – Contact us to apply:

Charity Care. We understand that medical expense are often

unexpected. Charity Care is available for patients who meet

eligibility criteria. Charity Care is secondary to all other financial

resources available to the patient. Contact a Patient Account

Specialist for more details at 308-254-8778 or to request a copy

of the application.

How to Apply - Apply by completing an application over the

phone, in person, online or via a mailed application.

Online: SidneyRMC.com/Charity Care Program Phone: 308-254-8778 In person at:

Sidney Regional Medical Center 1000 Pole Creek Crossing Sidney NE 69162

Payments options (cont.)

American Bank Points West Bank

Minimum Balance $500

7.5% to 10% interest

$50 Origination Fee

Credit Report (optional at bank discretion)

Minimum of 6 months of Employment

Proof of Gross Income (Pay stubs, W-2’s,

Tax Returns)

No previous charge offs or delinquency

with AB

For Balances $750 to 15000

7.5% Interest

$35 Origination Fee

Min Payment amount $100

Credit Report Required

Pay Online: www.SidneyRMC.com select “Pay Online” Pay by phone: Call us at 308.254.8778 Mail your payment to: SRMC Attn: PFS Dept 1000 Pole Creek Crossing Sidney, NE 69162-1714 Stop by Patient Financial Services: 1000 Pole Creek Crossing Sidney, NE 69162 Monday - Thursday 8am - 5pm Friday 8am - 4pm


Patient statements are referred to as guarantor statements.

A person is considered their own guarantor at the age of 19

in the state of Nebraska. If the patient is still on a parent’s/

caregiver’s insurance, that patient will receive a separate

statement due to being considered an adult in the state of

Nebraska.

If the patient is a minor, whoever signs consent for treatment

is the guarantor for that visit. In instances where a minor is

brought in separate times by a different parent, the parent

that signed consent will receive a statement for that visit.

Each time a patient or family member on the same

insurance contract comes in, a new visit will be created.

Each visit with any patient amount due will be on the

guarantor statement.

The profile number, located on the top right of the guarantor

statement, corresponds to the guarantor’s profile. Minors

and adults each have a profile number assigned to the

individual.

When calling to make a payment, please provide the

account number. See following page for location on

statement.

Guarantor statements

Page 23

In-network refers to providers or healthcare facilities

that are part of a health plan’s network. This means the

provider/healthcare facility has a contract with that

insurance company and have negotiated rates for

services and providers.

If SRMC is not in network with the patient’s health

plan, the patient may receive a bill for the services

received. It is always best to call the insurance prior to

receiving services to verify if SRMC and the provider

are in network. Below is a list of in-network insurance

companies with SRMC:

Aetna

Blue Cross and Blue Shield

Cigna (processing through Midlands)

First Health (processing through Coventry Health of Nebraska)

Coventry

Medicare

Medicaid - Total Care Medicaid

Medicaid - UHC Community Plan

Medicaid - Wellcare

Midlands Choice

Multi-Plan (Please contact your insurance company to verify your policy processes all service through Multi-plan)

United Healthcare

In-network insurance


Multiple payment options are available for your convenience.

Please include account number with payment. If paying via mail or in

person, please include the lower portion of the statement. For questions

regarding

how to pay

contact a

Patient

Account

Specialist.

Convenient payment options


Pay Online:

www.SidneyRMC.com

select “Pay Online”

Pay by phone:

Call us at 308.254.8778

Mail your payment to:

SRMC Attn: PFS Dept

1000 Pole Creek Crossing

Sidney, NE 69162-1714

Stop by Patient Financial Services:

1000 Pole Creek Crossing

Sidney, NE 69162

Monday - Thursday 8am - 5pm

Friday 8am - 4pm

Guarantor statements (cont.)

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjQ4be1pbzOAhVB8WMKHQ23Ah8QjRwIBw&url=http%3A%2F%2Fmoney.usnews.com%2Fmoney%2Fpersonal-finance%2Farticles%2F2013%2F05%2F02%2Fhow-to-raise-money-for-medical-bills&bv


Guarantor statements (cont.)

The guarantor statements have six columns (see sample

statement on page 14):

Date - the date the service was provided.

Patient admission/description - visit number and brief

description of the type of visit. If there is lab or radiology

done the same day you have a consult/visit with your

doctor, the description will remain consult.

Total charges - amount of total charges for that date of

service. For insured patients, this is the amount SRMC

bills to your insurance.

Patient payments - amount the patient has paid prior to

the statement date.

Insurance payments - amount the insurance has paid

and the amount discounted prior to the statement date.

Patient pay - balance due from the patient.

Patients should look over the EOB from insurance and the

guarantor statement from the servicing hospital to ensure

accuracy. If the EOB does not match the guarantor

statement, contact a Patient Account Specialist.

To set up payment arrangements, make a payment or

request an itemization of a visit, contact a Patient Account

Specialist.

Page 21

Questions need to be directed to the phone numbers

listed on statements.

Radiology Services

Advanced Medical Imaging (AMI) will send a separate

bill for interpretation/reading of your study.

Sleep Studies

Dr. Imes office, the polysomnographer doctor, for

interpretation/reading of your study.

Cardiac Event Monitor

Life Watch for the Rental Fee of the monitor.

Laboratory

Patients may receive a bill from University of Nebraska

Medical Center, Healthtronics, Prometheus or

Liposcience for some lab work.

Visiting Physicians

Specializing in Cardiology, neurology, pulmonology,

ophthalmology, audiology, ear nose & throat physicians

bill professional services directly from their office. A bill

from SRMC for the facility fees for services received by a

visiting physician will also be sent to the guarantor.

If a specialty provider choses to use an external service

(i.e. pathology on biopsies sent to a different lab), the

guarantor may receive a bill from the external service.

Additional billing statements

necessary care.

How to Apply - Apply by completing an application over the

phone, in person, online or via a mailed application.

Online: SidneyRMC.com/Charity Care Program Phone: 308-254-8778 In person at:

Sidney Regional Medical Center 1000 Pole Creek Crossing Sidney NE 69162

Applications are physically available at the SRMC’s

Admission and Patient Financial Services departments and

can be requested via mail by sending a written request to

the above address. The Patient Financial Services

department can provide assistance with the application

processes by being contacted at the above physical address

or phone number.

If there is knowledge, evidence or questionable information

within the application process, supporting documentation will

be required before eligibility is determined. Supporting

documentation may be requested on charity greater than

$5000. Supporting documentation include current year W-

2’s, tax return, vehicle registration, property tax evaluations,

bank statements, unemployment statement and may include

a Medicaid denial letter.

SRMC is not required to have this application available in

additional languages due to the demographics of our

population. However, if you need help we do have a

language translation line available to help us in assisting

you.

REFERENCES Collaboration with the Finance Committee of the Board of Directors, 2009 IRS Code Section 501; Medicare Fairbilling & Collections Act

Sidney Regional Medical Center Page 20

Charity Care (cont.)

Guarantor letters will be sent to the guarantor when visits

are scheduled for collections. If the visit is for a minor, the

letter will be sent to the guarantor who signed consent. If

payment arrangements were set up, but are not being met,

the visit will age resulting in a letter being sent.

If multiple visits have aged and are scheduled for

collections, the guarantor will receive one letter per each

visit.

The letter will only contain the patient’s name, patient

number (visit number), the balance on the visit, the day the

patient was discharged, and the patient type. Patient types

are:

Inpatient Outpatient Emergency room Clinic Extended care or long term care

To receive an itemized statement charges please contact

a Patient Account Specialists.

If payments have been made or to avoid being sent to

collections, please contact a Patient Account Specialists at

Guarantor letters



Guarantor letters (cont.)


Page 19

Overview

SRMC is committed to the provision of healthcare services

to all persons in need of medical attention regardless of

ability to pay. It is the policy of SRMC to treat all patients/

guarantors equally, fairly and consistently. Patients seeking

financial assistance can apply for charity care. You may be

eligible if you are not insured, underinsured, or not eligible

for sufficient coverage under any government program.

Charity Care is generally secondary to all other financial

resources available to the patient.

Eligible Services

Patients may be considered for charity care for medically

necessary service, on accounts with the current patient due

balances and accounts with service dates within 6 months

following the application approval date. When in question,

Medically necessary services shall be determined by the

examining physician.

Eligibility Requirements

Patients must be residents of Cheyenne or Deuel County

and/or a 20-mile radius of Sidney. Charity will be based on

household income and size, real estate, personal property

and investment equity, with credit to be given for already

existing medical loans, in comparison to the current year

Federal Poverty Guidelines. The HHS poverty guidelines are

published each year in the Federal Register. Free care will

be given to household that is at 100% of the poverty level.

Discounted care will be given at up to 300% of the poverty

level. Those that are eligible shall not be charged more than

the amount generally billed for emergency and medically

Charity Care

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