Hardship, Private Pay, Attorney Discount Agreement (BF-27, Rev. 0)City Of
ADMINISTRATIVE
SUBJECT:
BUDGET AND FINANCE
J
Delray
POLICIES AND
PROCEDURES
Hardship,
Attorney
Private Pay,
Discount Agreement
4
MANUAL
5
$ 28,780.00
6
$ 32,960.00
NUMBER
REVISIONS
EFFECTIVE
DATE:
PAGE
Beach
BF -27
0
09/25/2017
1 of 2
SUPERCEDES
APPROVED BY:
N/A
Neal de Jesus,
Interim
City Manager
BF- Purpose:
The purpose of this policy is to provide effective guidelines and procedures for approving or denying any
Hardship Request, Private Pay Discounts and Attorney Discount Agreements.
BF- Policy:
The EMS Billing staff shall follow the procedures for all Hardship Requests and Discount Requests
BF- Procedure:
I. Hardship Request and Private Pay Discount
Hardship Discount
1. Accounts for ambulance service can be discounted at a minimum of 30% up to 100% of the
total charges if the account meets the qualifying factors.
2. For the account to be considered, the patient must either be un- insured or under - insured.
Under - insured meaning, the insurance company has paid less than 50% of the total charges.
3. In order to qualify the patient must complete and return the application for Hardship Discount
and submit any or all documentation to support the request for discount; such as income tax
forms, unemployment documentation or a hospital charity letter. Based on the income level if
the patient is under the Palm Beach County Poverty levels no further information is needed.
Household Family Members
Annual Income -Less than $
1
$ 12,060.00
2
$ 16,240.00
3
$ 20,420.00
4
$ 24,600.00
5
$ 28,780.00
6
$ 32,960.00
7
$ 37,140.00
8
$ 41,320.00
9
$ 45,500.00
10
$ 49,680.00
Pagel
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4. It may be necessary for the EMS Billing office to call and verify all information submitted.
5. If the account is discounted less than 100 %, the patient must sign and return the monthly
payment agreement, the agreement will remain in place until the account is paid in full.
6. If the patient breeches the agreement, the agreement will be null and void in which the
discount shall be removed and the patient will be responsible for the total charges.
7. If the patient does not meet any of the qualifying factors, the EMS Billing Division may offer
payment plans for the patient or a 20% discount if the patient agrees to pay in full. The 20%
applies to companies hired to negotiate patient discounts as well. No more than 20% shall be
given unless the patient applies for Hardship.
Il. Attorney Settlement/Discount
In the event an Attorney request for a settlement of a patient's account is received by mail,
fax, e-mail or phone the account shall be considered for settlement or discount:
1. For the account to be considered, the patient must either be un- insured or under - insured.
Under - insured meaning, the insurance company has paid less than 50% of the total charges.
2. If an Attorney request for a settlement of a patient's account is received the division may
accept 50% of the remaining charges after insurance has paid or 50% of the total charges if
the patient has no coverage from any insurance.
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