Financial Hardship ApplicationThe patient will need to complete a financial disclosure form(see attachment B) andprovidedocumentation of proofof income. Appropriate documentation of financial hardship wouldbe oneor moreof the following:

1) Documented proofthat patientIsat or below 200% of the current federal povertygUidelines (see attachment B for 2008 guidelines). This can includedocuments suchas

a. W·2 withholding statementsb. Paycheck stubsc. Income tax returnd. Forms fromMedicaid or otherState-funded medical assistancee. Forms fromemployers or welfare agencies.

2) Patient hasothercircumstances that Indicate financial hardship. Thesecan be situationssuchas:

a. proofof bankruptcy setUementb. catastrophic situations (death or dlsabnity In family, diVOrce)c. or otherdocumentation that shows that patient would be unableto paymedical

biD andstill be able topayfor otherbasfc necessary expenses.

Income shallbeannualized fromthe dateof request based on documentation provided andupon verbal information provided by the patient The annualization process will also takeintoconsideration seasonal employment and temporary increases ami/ordecreases to income.

Anydenial of "financial hardship· discount request will bewrittenandwill include Instructionsfor reconsideration. If additional documentation of financial need is received to supportcharity care, the request will be reviewed andconsidered per the aboveguidelines.

Allinfannation relating to financial hardship requests will be kept confidential.

OIG Special FlaW Alert(111M). OIG AdviIoIy Opinion '"~. FIdenlI ReglIl8f. VOl85. No. 81, 4-26-00 pages 24401·2440742 CFR.1IlldIon1001.852 (k)HIPM, MdIon 231(h). Mellon 1121M2 USC. SectIon 1UO..7.BBA, MClioII4331 FaIN CIIIms Ad. PutlllcLaw 104-191.Kennedy v ConnedIcuI GeneraJ life Ins.Co(CUe Law) 924 F.2d898(7lh Or. 1991) Managed care Connda

1 FInancIalHardshipAppllcation

Attachment B

Financial Disclosure Form

Financial Hardship DiscountInformation Needed. HHSPovertyGuidelines-Used to-detennlnefinancial hardship based on Income.

2008 HHS Poverty GuidelinesPersons 48 contiguous

In Family or Household States and D.C. Alaska HawaII

1 $10,.WO $13,000 $11,960

2 14,000 17,500 16,100

3 17,600 22,000 20,240

4 21,200 26,500 24,380

5 24,800 31,000 28,520

6 28,400 35,500 32,660

7 32,000 40,000 36,800

8 35,600 44,500 40,940

For each additional 3,600 4,500 4,140Iperson, add

SOURQ: FetIeraI RJtgtstlN", Vol. 73, No. 15, January 23, 20OS, PP. 3971-3972

Please provide following Information so we maycomplete your application:

Q MostrecentIRS tax forms (1040 and/orW-2) (Mustbe signed)

lJ Check stubs for the past 30 days for all persons employed in the home.

a Unemployment checkstubsfor the past30 days.

a Drivers licenseor Identification card for adults.

Q Proofof all other Incomereceived in the past30 days.

[J Proofof all outstanding bills (paymentstubs, cancelled checks,etc.)

[J DSHS Denialletter.

1:1 Medicaid forms or card

lJ Attached financial statement(completely filled outand signed)

Please be sureto sign the attachedfinancial statement Your requestwill NOT be processed ifthisIs notsignedI

Please return all items(as applicable) on this checklist (In personor by mail).

Financial statement paymentplan/uncompensated services application.

-2 FInancialHardshipApplicatIOn

PATIENT NAME:

DATE(S) OF SERVlCE:

NAMEOF RESPONSIBLE PARTY:, _

RELATIONSHIP TO PATJENT:, _

SPOUSE:

TELEPHONE:

ADDRESS:, _

NUMBER OF FAMILYMEMBERS(LMNG IN HOUSEHOLD):, _

EMPLOYER: _

ADDRESS: _

IF UNEMPLOYED, HOW LONG?: _

SPOUSE'S EMPLOYER:, _

ADDRESS:, _

IF UNEMPLOYED, HOW LONG?:, _

OTHER FAMILYMEMBER'S EMPLOYER(S):

(INCLUDE MEMBER NAME,EMPLOYER, & ADDRESS

MONTHLY FAMILY INCOME &SOURCE

_Patient _Spouse _Responsible Party _Children Working

Monthly Salary(Gross)$ _

pubncAssistance Benefits $. _

Unemployment Benefits$, _

Social Security Benefits $. _

Wor1unan's Compensation $.__

3 Ananclal HardshipAppUc;allon

cw_ . ..4 ;;::;:::;au ¢ _. d.! . j R 1.: . ., .1.. . i :0_. .. xc ...

Child Support $, _

Other (Alimony, Etc.) $ _

TOTAL FAMilY INCOME$, _

I HEREBY ACKNOWLEDGE THATTHEINFORMATION GIVEN HEREIN IS TRUE ANDCORRECT. I AUTHORIZE [YOURCOMPANY] TOVERIFY ANY INFORMATION CONTAINEDINTHISDOCUMENT FORTHE SOLE PURPOSE OFASSESSING FINANCIAL NEED.

Signature of PeISOn MIlking Request Date:

Signature of Spouse1Other Date:

DONOTWRITE IN BOX- FOROFFICE PERSONNEL USEONLY

This document was received on (date)

by I(NamelTitle)

(signature of providerlpractlUoner or oIfic8 manager)

Approved by _-:-:'__-:- _

4 FInancial HaldshlpApplicatiOn

;; . _ I ==

72896 Federal Register / Vol. 67, No. 236/ Monday, December 9, 2002/ Proposed Rules

Department of Health and Human ServicesOffice of Inspector General

IT IS UNLAWFUL TO ROUTINELY WAIVE CO-PAYMENTS,DEDUCTIBLES, COINSURANCES OR OTHER PATIENTRESPONSIBILITY PAYMENTS.

This includes services deemed as "professional courtesy" and "TWIPS-Take whatinsurance pays". Absent financial hardship, a "good faith effort" must be made tocollect all deductibles and co-payments due and owed.

Failure to comply makes you in violation of the

(1) Federal False Claims Act

(2) Federal Anti-Kickback Statute

(3) Federal and State Insurance Fraud Laws

and may result in civil money penalties (CMP) in accordance with the new provisionsection 1128 A(a)(S) of the Health Insurance Portability and Accountability Act of1996 [section 231(h) of HIPAA].

For any questions please contact:

Office of Inspector GeneralDepartment of Health and Human Services:By Phone: 202619-1343By Fax: 202 260-8512By E-Mail: paffairs@oig.hhs.govBy Mail: Office of Inspector GeneralOffice of Public AffairsDepartment of Health and Human ServicesRoom 5541 Cohen Building330 Independence Avenue, S.W.Washington, D.C. 20201

Joel SchaerOffice of Counsel to the Inspector General(202) 619-0089

SafeGuardServices

LLC

CONFIDENTIAL

June'" 2011

• 2 Florida-,

Re: Provider Education

NPI #: -::::..WMM: I

Dean .

SafeGuard Services, LLC (SGS), is the Zone 7 - Zone Program IntegrityContractor(ZPIC)chosen by the Centers for Medicare & Medicaid Services(CMS) to perform specific programsafeguard functions for the Medicareprogram. Some of the program integrityfunctions are inthe following areas: medical review,cost report audit. data analysis, providereducation,andfraud detection, and prevention.

The Zone 7 - ZPIC responsibilities include reviewing the accuracy and justification ofallservices reimbursedby the program. The Zone 7 - ZPIC must ensure that the correctamount hasbeenpaid for covered and correctlycodedservices rendered to eligible beneficiaries bylegitimate providers. The purposeof this letter is to describe the steps involved in this auditprocessand the results, highlightbillingdiscrepancies, and provide educational information toassistwith your future claims for Medicare reimbursement.

FINDINGS

Thepurpose of this letter is to educateand inform you that on June" 2011, our office receiveda complaint alleging thatknowingly process MedicareClaims as if the patient is paying their co-payments but the patientsare not althoughMedicareshows the patientshave paid their percentageand pays the remainder.

EDUCATIONAL INFORMATION

Underthe federal law, Health Insurance Portability and Accountability Act of 1996(HIPAA),the Centersfor Medicare & Medicaid Services(eMS) defines Fraud as intentional deception ormisrepresentation that the individual makes,knowingit to be false and that it could result insome unauthorized benefit to them. Abusedescribes incidentsor practicesofproviders,

=====-;:::;-~"'':':-'='~ "·::.-c:.:: - - _._ _ . ..• _ . "'- " -'-'-' -~. • •_-.-_._.-. " ---'- - ..- ..-.-----.:==A CMS Zone Program Integrity Contractor. Medicare Program Integrity

3450 lakeside Drive, Suite 201, Miramar, Florida 33021Telephone: (954) 433-8200 Fax: (954) 433-6001

www.ureguard-servlcesllc.com

Page 2 of3WMM:'-__'"

physiciansor suppliers.or services and equipment which. although not usually fraudulent, areinconsistent with accepted sound medical. business or fiscal practices. These practices may,directlyor indirectly, result in unnecessary costs to the program, improper payment, or paymentfor services which fail to meet professionally recognized standards ofcare, or which aremedicallyunnecessary. Individuals convicted under these felony provisions may be fined up to$25,000or imprisonedup to five years, or both.

The Medicareand Medicaid Patient Protection Act of 1987.as amended, 42 U.S.C. §1320a-7b(the "Antikickback Statute"), provides for criminal penalties for certain acts impacting Medicareand state health care (e.g., Medicaid) reimbursable services. Enforcement actions have resultedin principalsbeing liable for the acts of their agents. Of primary concern is the section of thestatutewhich prohibits the offer or receipt ofcertain remuneration in return for referrals for orrecommending purchaseofsupplies and services reimbursable under government health careprograms. Section 1320a-7b(b) provides:

(1) whoever knowinglyand willfully solicits, receives or willfully offers and pays anyremuneration including any kickback. bribe or rebate- directly or indirectly, overtly orcovertly, in cash or in kind -

(A) in return for referring an individual to a person for the furnishingor arranging for thefurnishing ofany item or service for which payment may be made in whole or in partunder [Medicare] or a State health care program. or

(B) in return for purchasing. leasing. ordering. or arranging for or recommendingpurchasing, leasing, or ordering any good, facility. service, or item for which paymentmay be made in whole or in part under [Medicare] or a State health care program, shallbe guilty of a felony and upon conviction thereof. shall be fined not more than $25,000 orimprisoned for not more than five years, or both.

Thus, the AntikickbackStatute prohibits certain solicitations or receipt of remunerationand theoffer or payment ofcertain remuneration. Section 1320a-7b(b)(2) has generally been applied tobroker-style arrangements,whereby an individual offers remuneration to another individual forthe purposeof recommendingor referring an individual for the furnishing or arranging for anitem or service. In an Antikickback Statute analysis, it is immaterial whether remunerationinducesone in a position to refer or recommend. It is sufficient that the remuneration may induceone to refer or recommend.United States v, Greber, 760 F.2d 68, 71 (3rd Cir.), cert. denied, 474U.S. 988 (1985). Under Greber, it is also irrelevant that there are other legitimate reasons for theremuneration. If one purpose is to induce referrals, then the Antikickback Statute is violated. Id.at 71.

The AntikickbackStatute contains certain exceptions, which allow conduct that would otherwiseviolate the statute, such as certain discounts given by suppliers to cost-reporting providers.Finally, the statute permits the Secretary ofDHHS to promulgate regulations which identifyother practices which do not violate the Antikickback Statute. In this latter case, the Secretary ofDHHS has promulgatedapproximately numerous "safe harbors", found at 42 C.F.R. §1001.952,which, if the requirementsare met, insulate individuals and entities from prosecution under theAntikickback Statute for conduct which would otherwise violate the Antikickback Statute.

Page 3 of3WMM_

Althoughcompliancewith a regulatory safe harbor is not required if the written agreements orarrangements between parties under consideration do not fan within the Antikickback Statute inthe first instance, the safer course is to evaluate "grayarea" agreements in the context of theregulatorysafe harbors. The safe harbor regulations, however, are rather narrowly drafted andthereforemake compliance with them difficult.

Pleasebeadvised that the Office of Inspector General released an alert regarding the issue onroutinelywaving copayments for Medicare patients. Here is what it says, "In certain cases, aprovider,practitioneror supplier who routinely waives Medicarecopayments or deductiblesalsocould be held liable under the Medicare and Medicaidanti-kickback statute. 42 U.S.C. 1320a­7b(b). The statutemakes it illegal to offer, pay, solicit or receive anything of value as aninducement to generatebusiness payable by Medicareor Medicaid. When providers,practitioners or suppliers forgive financial obligationsfor reasons other than genuine financialhardshipofthe particularpatient, they may be unlawfully inducing that patient to purchase itemsor services from them." Ref: http://oig.hhs.gov/fraud/docs/alertsandbulletinsl121994.html.

The criminal statute applies regardless ofwhether the payment for referral is made directly orindirectly, overtly or covertly, in cash or in kind.

Youroffice should review the CMS manuals, guidelinesand regulations to ensure you are incompliancewith all Medicare rules and regulations.

Pleasebe advised, this letter is intended to be educational in regards to the appropriatesubmissionofMedicareclaims. You may be subject to a follow-up review ofyour billingpractice in the future to ensure compliance with the informationand recommendations in thisletter. Additionally, continuation ofidentified problemscan result in exclusion from theMedicareProgram in accordance with Section I128(b)of the Social Security Act; CivilMonetaryPenalties; and/or suspension ofMedicare payments under Title 42 of the C.F.R.,Section 405.370 et seq.

If you have any questions or concerns, please contact SGS Complaint Analyst••••••at our customer service number (954) 433-6200.

Sincerely,

E yn Gi MorComplaintsFraud ManagerSafeGuardServices, LLC - A CMS Zone Program IntegrityContractorMedicare Integrity Program

S:\Website Additions\Documents\Medicare Financial Hardship Application.pdf