In July 2023, the United States Consumer Financial Protection Bureau, the Department of Health and Human Services, and the Department of the Treasury solicited public comment on medical credit cards, loans, and other financial products used to pay for health care. Dollar For prepared and submitted a comprehensive report based on our experiences supporting patients with medical debt. The following is a full transcript of our public comment.

Consumer Financial Protection Bureau Docket No. CFPB-2023-0038
Department of Treasury Docket No. TREAS-DO-0008
Department of Health and Human Services Docket No. CMS-2023-0106

Submitted by Dollar For, September 2023

Introduction to Dollar For

Dollar For is a national 501(c)(3) nonprofit organization that helps patients with charity care applications. We also advocate for better and fairer administration of charity care policies by tax-exempt hospitals. We maintain the largest known database of hospital charity care policies in the United States. This database powers a screener to help patients determine if they are eligible for charity care at their hospital. We then help eligible patients to prepare and submit charity care applications and advocate on their behalf. Since 2019, we have helped patients submit over 7,600 applications and have helped relieve over $31 million in hospital bills. 

Executive Summary

The Consumer Financial Protection Bureau, the Treasury Department, and the Department of Health and Human Services are seeking comments to learn, in part, how hospitals are using and promoting medical payments products in place of other lower cost alternatives. Dollar For, a national non-profit focused on making charity care known, easy, and fair, has a unique perspective based on our experience helping over 7,600 patients navigate hospital financial assistance programs.

In this public comment, we seek to show how hospitals nudge patients away from financial assistance and towards higher cost financing programs. We deem this behavior as a primary problem with any use of medical payment products, given that any issues related to kickbacks or fees would be moot if the patient had been properly screened and offered charity care in the first place.

This public comment thoroughly documents the tactics that hospitals employ to misdirect patients away from charity care. These include (1) presenting  medical payment products as a “financial assistance” options on bills and website,  (2) using phone trees and staff interactions to create easy on-ramps to financing options, and (3) developing  deeply complicated application processes for charity care in stark contrast to the simple processes offered to obtain financing.

Hospitals often obfuscate the concept of Financial Assistance (as the term is used in 26 USC 501(r)) by listing both charity care and medical payment products as “financial assistance options” on their websites. These same websites very clearly and concisely convey the benefits of using a medical debt product, who is eligible and for how much, and how a patient applies. Descriptions of charity care, on the other hand, are often vague, long, and confusing to a layman.

Communicating with the hospital about financial assistance presents similar challenges. Calling a  hospital’s financial assistance department often requires first speaking to the billing department. Patients are put on hold, where they hear recorded messages about the hospital’s payment plans. Once connected,  the patient often must interact with a billing department representative with no knowledge of charity care, and often assumes the patient is seeking a “payment plan.” 

Yet still, the self advocacy doesn’t end when a patient succeeds in submitting a charity care application. Patients are required to submit a myriad of documents proving their income, expenses, and spending habits, often in very specific and unreasonable formats. They must follow up with the hospital over weeks or months to make sure the application actually moves forward. And if they are unjustly denied financial assistance, they must then navigate a complicated appeal process.

Alternatively, medical debt financing is often approved within minutes. Patients must simply answer several questions on a mobile-friendly online form. Looking at these two processes in parallel, it’s clear that hospitals are effectively and intentionally steering patients away from charity care and into third-party medical debt financing products.

Dollar For urges the Department of the Treasury, the Consumer Financial Protection Bureau, and Department of Health and Human Services to implement regulations requiring hospitals to substantively screen every patient for charity care – before they are permitted to offer or enroll the patient in an internal payment plan or third-party financing. Regulations could also ensure that hospitals cannot easily deny patients charity care on procedural grounds. 

Further, Dollar For urges the Consumer Financial Protection Bureau to bring enforcement actions against tax-exempt hospitals that nudge patients away from charity care and towards medical payment products. 

We believe these tactics are unfair, deceptive, and abusive acts that violate the Consumer Financial Protection Act. Given that hospitals are not traditional finance or credit companies, it is not apparent on its face that they are subject to the CFPA. However, case precedent makes clear that the practices outlined in this comment are financial advisory services – and therefore are governed by the CFPA. Hospitals also act as “service providers” to the medical bill financing companies – providing additional grounds for standing.

The trends and concerns outlined in this public comment will only grow in the coming months and years. Strong regulations and enforcement are needed to protect healthcare consumers across the country. 

Market Level Inquiry Question 12 & Treasury Specific Question 4 

RFI Market Level Question 12: To what extent are patients using medical payment products to pay bills that are incorrect, or that could be covered or defrayed by lower-cost alternatives?

RFI Treasury Specific Question 4: How do tax-exempt hospitals’ promotion of medical payment products compare to their operationalization of the requirement that their financial assistance policies be widely publicized?

Hospitals are taking advantage of deficiencies in charity care laws, specifically the regulations in 26 CFR 501(r), to steer patients away from charity care and toward financing products.

Our current charity care system places the burden on the patient to ask to be screened for eligibility instead of requiring hospitals to proactively screen patients. This means that patients must both be aware of charity care and take action to apply. Yet, many hospitals make it far easier to learn about their financing options than charity care. If a patient does learn about charity care, many hospitals make financing debt extremely easy and getting charity care extremely hard.

Learning About and Understanding Charity Care

Many hospitals hide their charity care program in plain sight. The most aggressive and deceitful hospitals explicitly train their staff to attempt to get patients to sign up for payment plans before telling them about charity care. This was well documented by the 2022 case filed by the Washington Attorney General’s office against Providence. 

Other hospitals employ a series of subtler tactics, or “dark patterns” to nudge patients into consumer debt products couched as “payment plans” and away from charity care. These include but are certainly not limited to:

• Obfuscating “financial assistance” by presenting both charity care and financing as “financial assistance options.” 
• Structuring hospital phone trees so that all roads can lead to a hospital billing office but few or none lead to the charity care department.
• Offering patients the option to pay a bill over the phone 24/7 but requiring they leave a voicemail when trying to reach the charity care department.
• Clearly and prominently explaining their “payment plans” in invoices but use unclear language to discuss charity care.

Charity Care Process

Most charity care applications must be physically acquired from the hospital or downloaded as a .pdf file from the hospital website. This on its own is a massive hurdle to many patients. Many patients, especially those who are lower-income, primarily access the internet on their phones and can’t easily access a printer. Next, most hospitals require applications to be either personally dropped off, mailed, or faxed into the hospital – requiring additional time, tools, and technology that most lower-income patients cannot easily access. 

Patients are frequently required to gather an absurd amount of documentation to prove their income and financial situation. Some of the most egregious examples we’ve seen include:

• Policies that require patients to provide three months worth of bank statements along with a written description of every transaction exceeding $100.
• Unemployed patients asked to provide a letter from their pastor, lawyer, or doctor describing why they could not work. 
• Hospitals refusing to accept “pictures” of requested documents.
• Hospitals refusing to accept online print-outs of bank statements for a patient who banked at an online-only bank.

Typically, if patients do not provide all documents listed in the hospital’s financial assistance application in the exact format the hospital demands, they are given a strict, arbitrary, and illegal “deadline” to provide the missing information. This deadline can be as short as 10 days and is rarely longer than 30 days. Otherwise eligible patients who do not or cannot supplement their application in time are often denied and barred from re-applying. 

Dollar For regularly has to submit applications multiple times to hospitals who claim the application was never received, even when we have fax confirmations to prove application dates. Dollar For patient advocates frequently have to follow up with hospital staff multiple times, usually over the course of months, before a hospital will actually process a patient’s application to make an eligibility determination. 

Further, many hospitals continue the collection process during this time. Many will still refer the debt to a debt collector or sell it to a finance company while a charity care application is pending. Patients can be very confused when they have applied for financial assistance but the hospital or their collection agency continues to demand payment. Many patients facing this system on their own are likely to either pay or finance the bill, or live with the stress for months on end.

If the patient makes it through that process, they may be granted charity care. However, many are not and must go through the hospital’s appeal process. Most appellate processes (if a hospital has one) are similar to the application process except with more confusion.

Financing Process

By contrast, to take out a credit line with the hospital’s debt product of choice patients usually just need to fill out a one-page mobile friendly form or talk to a single person over the phone and the bill is “paid off” in minutes. A screenshot of a financing application is attached as Appendix N.

Misleading Websites

The following are examples of hospitals that use their website to steer patients away from charity care and towards financing products. Screenshot captures of all referenced websites are linked below. This is only a handful of examples and is not an exhaustive list:

Harbor Regional Health

Harbor Regional Health’s charity care information is located on the page labeled “charity-care-financial-assistance” in the URL. It is accessed from the homepage by clicking on the dropdown labeled “Charity Care – Financial Assistance” in the “About” section. The top section of the page is “Tax Credit Policy.” Near the top of the page, before it references anything about charity care, it directs patients to set up a payment plan and links to CarePayment’s website.

The description about how its financing program works is in neat, short, bullet points that quickly and clearly convey how financing works, how one applies, and who is eligible.

The description of the hospital’s charity care program is not in clear, neat bullet points like the description of its debt product. It is large block paragraphs of text that vaguely describe the program. It lacks crucial information such as how much money (in dollars) a person of a certain household size can make and be eligible for a discount.  

Cone Health

Cone Health’s website lists the debt product AccessOne MedCard as one of its “Financial Assistance Programs” alongside its charity care program. Further, in the introductory description at the top of the page ostensibly meant to explain what financial assistance programs are, Cone Health describes financial assistance as a “feasible payment plan.”

Allina Health

Allina Health lists five sections in its financial assistance website page. The first section at the top of the page is “[c]all us to discuss special circumstances or to set up a payment plan.” The second section is information about charity care, and the third section is information about financing with MedCredit Financial Services. If the patient follows the link for financing they reach a mobile-friendly application for debt to pay their bill at 2 – 5% interest. 

Not only does this website reference setting up a payment plan before it references its actual charity care program, it displays this information using a numbered list instead of bullet points. This signals to the patient that these options are in some ordered priority or are steps the patient should follow – the first being to set up a payment plan. 

FirstHealth of the Carolinas

FirstHealth of the Carolinas lists information about financial assistance on the “Billing and Insurance” section of its website. The page has several collapsible sections on different ways to pay a bill, information about insurance, etc. One of the collapsible section labels says “Financial Assistance.” The section gives information about both the hospital’s charity care program but also its financing options through “Mosaic Finance Solutions.” This program claims to finance the debt at 5.25% APR.

CaroMont Health

On CaroMont Health’s website entitled “Financial Assistance,” it lists several options for patients including certain discounts for the uninsured or people who pay promptly, and different options for paying a bill. The second to last option discusses options for “Bank Financing” with CaroMont’s third-party lender. The “Charity Care Program” is the very last option at the bottom of the page.

The description of bank financing is simple and clear. It uses bullet-points to highlight key, quickly digestible information about how financing works and how a patient can acquire it. The description of charity care, however, is vague and confusing. The hospital says patients can “discuss” charity care with them, and links to more confusing language in the hospital’s charity care policy. 

Misleading Phone Systems

The following is an example of hospital phone systems that steer patients away from charity care and towards financing products. This is merely one demonstrative example and is far from exhaustive:

Atrium Health

On Atrium Health’s website page entitled “Financial Assistance” at the top, it discusses its various financial assistance programs and links to where users can find its policies and applications. On that page it lists a phone number that it claims is for its “Patient Customer Service” department. When a patient calls that number, they hear: 

“Welcome to Atrium Health. Para español, oprima dos. Thank you for calling Atrium Health customer service department. Please listen carefully to our menu as the options have changed. Did you know that my.atriumhealth.org allows patients to view and pay accounts, view and enroll in electronic statements, create payment plans, request itemized bills, and more? For the fastest service please visit us at my.atriumhealth.org. If you would like to use our express system to make a payment, request an itemized bill, or check your balance, press 1. If you are calling about something else, please press 2.”

If the user presses 2 (ostensibly the only option that does not involve paying a bill) they are routed to the “centralized billing” department. Dollar For patient advocates have found that representatives in the centralized billing department cannot assist with financial assistance matters. If a patient has the wherewithal to self-advocate for financial assistance anyway, centralized billing may give them a separate phone number that is not on Atrium’s website for the financial assistance office. However, they cannot transfer the patient, who must hang-up and call the new number they were given. 

Atrium’s website says that they can set up a “payment plan” with AccessOne in their MyAtrium Health patient portal. So, even if a patient finds out about financial assistance, goes to the hospital’s financial assistance page, and calls the phone number that is held out as being the financial assistance department, they will have to listen to a recording that tries to direct them to my.atriumhealth.org for the “fastest service,” get connected to a billing department regardless of whether they selected option 1 or option 2, and be sophisticated enough to demand to talk to the actual financial assistance office, be given that phone number, hang up, and dial the new phone number the billing office gave them. However, all avenues will allow them to set up a “payment plan” with AccessOne.

Misleading Invoices

The following are examples of hospitals whose invoices make it far easier to learn about financing debt than to learn about charity care. Images of the invoices discussed below are attached as Appendices L-M These are merely examples and are not an exhaustive list:

Virginia Mason Franciscan Health

The CHI Franciscan Health bill makes it exceedingly clear in multiple places that a user can sign up for a “payment plan.” The bill even calculates what the user’s monthly payment would be and presents it on the bill in large, bold, clear text. However, the information about financial assistance is in tiny font, does not describe the benefit to the program with any detail, and is buried under the “Contact Us” section. A copy of a CHI Franciscan Health bill is available on their website in a section describing how to interpret their bill.

It is unclear if the “monthly payment plan” referenced on the above bill is through a third-party financing product. However, CHI Franciscan does advertise CareCredit as a financing option on its website.

Mayo Clinic

Mayo Clinic posts a sample image on its website ostensibly to aid patients in interpreting their bill. It clearly conveys that patients have the option of a payment plan. It even calculates how much the patient’s monthly payments would be. This is displayed in large, bold, prominently displayed numbers with a clear description on the invoice. However, any reference to charity care is in small font under the “Contact Us” section of the invoice.

Processes to Apply

The following are examples of hospitals that make accessing debt far easier than charity care. These are merely examples and are not an exhaustive list:

Banner Health

Banner Health’s website page entitled “Financial Assistance” discusses its charity care program and links to its relevant policies and its .pdf file charity care application. It also has a link that says “Learn more about payment plans and financing options.” When a user clicks on that link they are given information about Curae financing which is advertised as 0%. When the user follows the link they can fill out a simple form on a mobile-optimized webpage and have their bill “paid off” immediately. Small text in the footer of the Curae application page says:

*Subject to credit approval

**$28 minimum monthly payment is estimated based on $1000 financed at 14.99% APR for 48 months. Actual APR varies between 0% and 29.99% and repayment terms vary between 24 and 48 months, depending on your creditworthiness. Payments will vary depending on loan amount and offer received. All Curae revolving accounts are issued by The Bank of Missouri, St. Robert, MO

Disclaimer: Curae provides financing up to $10,000 that can be applied to balances on services rendered at any Banner Health hospitals or outpatient facilities. At this time, Curae financing cannot be applied to Banner Imaging, Atlas Surgery Center and Banner Urgent Care balances, however, we plan to expand facility acceptance in the near future. If you have questions or require additional assistance, please call 1-888-264-2127.

Receiving financing through Curae is near instant. A user can access the form on their phone and provide the following information: 

• First name;
• Last name; 
• Date of birth;
• Social security number; 
• Phone number;
• Email address;
• Household income; 
• Estimated bill amount; and 
• Address. 

With that information their bill can be paid off by Curae in seconds. An image of the Curae application is attached as Appendix N.

To receive charity care a patient must fill out a .pdf form (which either requires specialized editing software such as Adobe or a printer) that asks for: 

• The facility the patient went to; 
• The patient’s account number; 
• Patient name; 
• Patient social security number;
• Patient address;
• Patient phone number;
• Guarantor name; 
• Guarantor social security number;
• Guarantor address;
• Guarantor city;
• Guarantor address;
• Guarantor phone number;
• The name of every household member;
• The relationship to the patient of every household member;
• The age of every household member;
• A designation of whether every individual household member is a dependent of the patient;
• A complete copy of the patient’s prior year’s federal income tax return;
• Copies of the last four consecutive payroll stubs for the patient/guarantor and their spouse;
• If the patient is self-employed, a copy of their federal tax form Schedule C;
• If the patient is retired or receives social security, a copy of their SSA 1099 form;
• Copies of any outstanding medical bills including doctor bills, ambulance, etc.

The above information must be compiled and mailed to:

Banner Health Patient Financial Services
Attn: Financial Assistance Department
P.O. Box 18
Phoenix AZ 85001

A patient then must usually wait months and will likely be required to follow up with the hospital multiple times. In many instances patients will have to submit the entire application more than once. 

Piedmont 

Piedmont also utilizes the debt product Curae. The Curae application asks for gross household monthly income. It also contains this statement in the footer discussing interest:

**$28 minimum monthly payment is estimated based on $1000 financed at 14.99% APR for 48 months. Actual APR varies between 0% and 29.99% and repayment terms vary between 24 and 48 months, depending on your creditworthiness. Payments will vary depending on loan amount and offer received. All Curae revolving accounts are issued by The Bank of Missouri, St. Robert, MO

Receiving financing through Curae is near instant. A user can access the form on their phone and provide the following information: 

• First name;
• Last name; 
• Date of birth;
• Social security number; 
• Phone number;
• Email address;
• Household income; 
• Estimated bill amount; and 
• Address. 

With that information their bill can be paid off by Curae in seconds. 

To receive charity care a patient must fill out a .pdf form (which either requires specialized editing software such as Adobe or a printer) that asks for: 

• The date of service
• The facility attended
• Patient full name
• Patient social security number
• Patient date of birth
• Patient physical address
• Patient mailing address
• Patient medical record number
• Patient phone number
• Name of the person completing the application
• The person completing the application’s relationship to the patient
• The name of every household member
• The date of birth of every household member
• The age of every household member
• The relationship to patient of every household member
• The occupation of every household member
• The social security member of every household member
• The annual income of every household member
• The total household income
• How much of the household income is from income
• How much of household income is from social security
• How much of household income is from other income/alimony/investments/retirement
• 401k balance
• Mortgage amount
• Rent amount
• Savings account balance
• Change healthcare verification
• If the patient has no income a description of how they are supporting themself
• Whether the patient has health insurance
• If the patient has any third-party liability such as auto insurance or worker’s compensation
• Whether the patient has Medicaid
• Whether the patient has applied for Medicaid
• Whether the patient is pregnant
• Whether the patient is on social security disability
• Whether the patient is over 65
• Whether the patient is 19 or younger
• Whether the patient is a custodial parent and unemployed
• Either a driver’s license, State ID card, passport, military ID, consular or school picture ID, or a Visa or Resident Alien card
• Proof of residency that is not more than 30 days old which can be either a lease contract, food stamps letter, utility bill with physical address, or other business documents such as credit card statement, IRS, Medicaid letter, student letters from school, bank statements, or mortgage statements.
• Proof of income
  • If the patient is employed this must be the three most recent paycheck stubs for the patient and their spouse
  • If the patient is unemployed they must provide an unemployment claim or award letter and copies of the three most recent bank statements for all checkings or savings accounts
  • If the patient is self-employed they must provide copies of the three most recent bank statements for all checkings or savings accounts for any personal and business accounts for both the patient and their spouse/partner
  • If the patient is retired they must provide a social security letter (if applicable) and copies of three months’ recent bank statements from both personal and business checking and savings accounts for the patient and their spouse/partner. The patient must also provide a Medicare SSN letter.
• Any decision letters indicating that the patient is receiving unemployment compensation, Medicaid, Social Security Disability, General Assistance, etc.
• Food Stamps Letter
• Verification of homelessness or a letter from a shelter on company letterhead
• Other business documents showing how the patient is being supported
• Proof of number of dependents in one of the following forms
  • Previous years signed income tax return
  • Any decision letters indicating that the patient has legal responsibility for the child, such as, court ordered guardianship papers or custody papers

All of the above information must be mailed, faxed, or emailed to the hospital. While a patient has 245 days from the date they receive their first post-discharge bill to begin an application for charity care, if a patient begins an application that does not include any of the above information that applies to them Piedmont will deny the patient charity care if they do not supplement with any missing information within 30 days. It is worth noting that this is impermissible under 501(r). See 26 CFR 1.501(r)-1(b)(3) and 26 CFR 1.501(r)-6(c)(5)(ii) (“If an individual who has submitted an incomplete FAP application during the application period subsequently completes the FAP application during the application period (or, if later, within a reasonable timeframe given to respond to requests for additional information and/or documentation), the individual will be considered to have submitted a complete FAP application during the application period…”).

On the section of the website that discusses financial assistance there is a phone number listed for the “Patient Financial Care team.” If the user calls that phone number outside of business hours the only option is for them to make a payment through the automated system. There is not even the ability to leave a voicemail.

Individual Inquiries Questions 1 & 7

RFI Individual Inquiry Question 1: Have medical payment products ever been marketed to you, including by your health care provider? If so, please describe your experience and how the products were marketed to you. Were other options, such as financial assistance, marketed or explained at the same time?

RFI Individual Inquiry Question 7: Have you ever used or been pressured to use a medical credit card or loan to pay a bill that you believe should have been covered by your health care provider’s financial assistance policy? If so, please describe your experience.

Dollar For has helped several patients who were eligible for charity care but were instead put on a “payment plan” financed by a third-party. Below are just a few examples.

Henry Mayo Newall

Dollar For helped a patient who received services at Henry Mayo Newall in California. He had put off seeking medical treatment for a long time because he was worried about the cost. However, one day he started having trouble breathing and, upon his family’s insistence, he went to the emergency room. Ultimately he was hospitalized for one day for Covid. 

After receiving the approximately $14,000 bill, the patient called the hospital to tell them he could not afford it. He was never told about charity care. Instead he was transferred to a representative with Commerce Healthcare. By the end of the phone call the patient had taken out a loan with Commerce Healthcare. The patient never signed any documents and does not remember being given any written disclosures. In fact, when Dollar For advocates approached the hospital and learned that the debt was sold to Commerce Healthcare the patient was confused by this — he did not realize he took out a loan. Dollar For applied for financial assistance regardless. Dollar For submitted the patient’s charity care application with accompanying documentation in February, 2022.

In late March, 2022 the patient called Henry Mayo Newall to follow up. They were told that the patient did not owe anything to Henry Mayo because Commerce had paid off the loan, so the patient should be contacting Commerce. Dollar For patient advocates re-engaged with the hospital for the next several months to follow up and advocate on the patient’s behalf. On August 10, 2022 Henry Mayo Newall finally granted 100% charity care, which the patient was entitled to the entire time. In the intervening months the patient paid over $3,100 to Commerce Healthcare towards the loan. It took more than a year of advocacy for Henry Mayo to finally refund the patient the amount he paid to Commerce – which they finally did in August, 2023. 

Mayo Clinic – Franciscan Medical Center

In this case, the patient was diagnosed with a disease that required ongoing treatment. They reached out to the hospital for help with their $7,100 deductible payment. The Mayo Clinic never told the patient about charity care and only referred them to the debt product Clear Balance. The patient, under the belief that they had no other choice, took out a loan with Clear Balance and was on a payment plan. The patient was never given any explicit disclosures from Clear Balance. They only remember checking a box agreeing to terms, but were never given any clear or conspicuous disclosures about how the loan works, what the interest rate may be, or how interest may accrue.

Eventually the patient learned of Dollar For and reached out for help. Dollar For applied for financial assistance with the Mayo Clinic in December, 2022. The Mayo Clinic approved the patient for a 50% charity care discount. However, Clear Balance only applied that discount to the remaining balance. They did not send a 50% refund for the $1,500 the patient had already made in diligent payments. To date both the Mayo Clinic and Clear Balance have refused to refund the patient 50% of what they paid prior to being approved for charity care.

Orlando Regional Medical Center

A patient of Orlando Regional Medical Center’s debt was transferred to Care Payment before the patient learned about Dollar For, who informed her about charity care. Dollar For helped the patient fill out a charity care application, gather necessary documentation, and submitted the application on the patient’s behalf. Dollar For has followed up with the hospital multiple times with varying excuses why the hospital has not granted charity care. Over two months after submitting the charity care application a Dollar For patient advocate emailed the hospital to follow up. The hospital responded with the following email:

Good morning,

Thank you for contacting us we hope all is well. We have received your Financial Assistance application we appreciate the information received. We are waiting to hear back from CarePayment and the process may take up to Thirty (30) days or more. Once we obtain an update, we will further review the application. Patient will receive a letter of determination to the mailing address on file once completed.

Please advise if you have any further questions.

Approximately a week later a patient advocate called the hospital to follow up. They were told that the patient was denied because they are “over income.” The patient advocate explained that the application clearly states that the patient’s household income is $40,584 and states the household size is four. It states that the patient is married and lists personal details for two dependent children. This meant the patient is at 135% of the federal poverty level and clearly eligible for 100% financial assistance. The hospital representative kept repeating that the patient’s household size is one, however given that the application clearly states the household size is four he could not explain why he believed the household size was one. He suggested the patient “update” their household size –without explaining how one would do that when they properly filled out the application indicating a larger household size. He also indicated there was nothing he could do. He went on to make vague statements about the patient’s income exceeding their expenses, that the patient seemed to have “assets,” and that making that much money for a household of one is “pretty nice” — ignoring the fact that the actual household size is four. A transcript of this call is attached as Appendix D. This matter is unresolved.

Ochsner Medical Center

A patient of Ochsner turned to Dollar For for help when they could not pay a bill. Dollar For, through its normal process, helped the patient fill out the hospital’s charity care application, gather all necessary documentation, and submitted it on the patient’s behalf within the 240 day application period. Ochsner denied the patient’s application. Dollar For patient advocates followed up with the hospital via phone. Ochsner repeatedly told Dollar For patient advocates that the patient had no balance on their account and alleged that the patient may have told Dollar For the wrong hospital. Ultimately, through advocacy, Dollar For uncovered that the patient had the right hospital, but the hospital had already sold the debt to ClearBalance. Dollar For staff have repeatedly requested that the hospital pull the bills back from ClearBalance and apply charity care, as the patient is eligible and timely applied. The hospital has refused to do so and has claimed that the hospital “cannot pull a balance from ClearBalance.”

Transcriptions of calls between Dollar For patient advocates and Ochsner are attached as Appendix C. 

Atrium Health

Before finding Dollar For, a patient received services from Atrium Health in January, 2020; in August, October, and December of 2021; and in January and December of 2022. Atrium had sold much of the patient’s debt to AccessOne – their integrated “payment plan” partner. The patient contacted Dollar For out of desperation because she had new bills and was afraid they would be sent to collections. Dollar For submitted a charity care application for this patient in February, 2023. The patient made $1,607.86 per month in a household of 1. That placed the patient at 141.9% of the federal poverty level — well below Atrium’s income requirements for charity care. However, three months after the patient applied for charity care and 1 month after her bills were sent to a debt collector Atrium sent the patient a letter denying her any charity care. The reason for the denial was that all of her bills except for those associated with the December 2022 stay were too old. 

Olathe Medical Center

A patient received services from Olathe Medical Center and, after finding themselves unable to pay, came to Dollar For for help. Dollar For helped the patient apply for charity care. In March, 2023 Dollar For helped the patient apply for charity care. The application showed that the patient made $2,240 per month and had a household of two, placing her at 136% of the federal poverty level. In the general comments section of the charity care application the patient wrote, in part:

Im still trying to pay a hospital bill off from Olathe Medical a year ago. Still have a balance $1726. I struggle to pay that at Commerce Bank.

Dollar For has heard from neither the hospital nor the patient as to whether the hospital ever processed the financial assistance application. What is clear from the patient comments, however, is that Olathe did secure a line of credit at Commerce Bank for the patient instead of pursuing charity care.

CFPB Specific Question #1 

RFI Question: What actions should the CFPB consider taking to address problematic practices related to medical credit cards or loans, including debt collection and credit reporting practices?

The CFPB should bring suit against hospitals who promote “payment plans” to charity-care eligible patients. Whenever a patient finances charity-care eligible funds, the hospital has very likely engaged in unfair, deceptive, and abusive acts. This is especially true in the context of prohibited abusive acts.

Pursuant to the Consumer Financial Protection Act (CFPA):

(a)In general

It shall be unlawful for—

(1)any covered person or service provider—

(A) to offer or provide to a consumer any financial product or service not in conformity with Federal consumer financial law, or otherwise commit any act or omission in violation of a Federal consumer financial law; or

(B)to engage in any unfair, deceptive, or abusive act or practice;

…

(3)any person to knowingly or recklessly provide substantial assistance to a covered person or service provider in violation of the provisions of section 5531 of this title, or any rule or order issued thereunder, and notwithstanding any provision of this title, the provider of such substantial assistance shall be deemed to be in violation of that section to the same extent as the person to whom such assistance is provided.

The CFPB has broadly described what constitutes an abusive act as:

The statutory text of these two prohibitions can be summarized at a high level as: (1) obscuring important features of a product or service, or (2) leveraging certain circumstances to take an unreasonable advantage. The circumstances that Congress set forth, stated generally, concern gaps in understanding, unequal bargaining power, and consumer reliance.

No rational patient would choose to finance debt that was eligible for charity care. It is difficult to imagine a scenario where a patient financed charity-care eligible debt that is not the result of gaps in the patient’s understanding about their options, unequal bargaining power between the patient and hospital, or the patient’s reliance on representations by the hospital — or a combination of all three. 

As documented in this public comment, the messaging of charity care and “payment plans” by hospitals, the structural barriers that make accessing charity care harder than financing, and the overall friction in the charity care process that is removed in the financing process are actionable abusive acts under the CFPA.

Hospitals engaged in this conduct are “covered persons” under the CFPA. “Covered person” is defined as:

(A)any person that engages in offering or providing a consumer financial product or service; and

(B)any affiliate of a person described in subparagraph (A) if such affiliate acts as a service provider to such person.

Hospitals fit squarely within the definition of “covered person” because they engage in “financial advisory services” to charity care eligible patients who are nudged towards financing their debt instead. The CFPA lists multiple actions that meet the definition of “financial product or service.” Among them are:

[P]roviding financial advisory services (other than services relating to securities provided by a person regulated by the Commission or a person regulated by a State securities Commission, but only to the extent that such person acts in a regulated capacity) to consumers on individual financial matters or relating to proprietary financial products or services (other than by publishing any bona fide newspaper, news magazine, or business or financial publication of general and regular circulation, including publishing market data, news, or data analytics or investment information or recommendations that are not tailored to the individual needs of a particular consumer), including—

(I)providing credit counseling to any consumer; and

(II)providing services to assist a consumer with debt management or debt settlement, modifying the terms of any extension of credit, or avoiding foreclosure.

Federal courts have found similar conduct by non-financial entities to meet the definition of “financial advisory services.” One prominent example is the holding by the Southern District of Indiana in the CFPB’s action against ITT Education Services, Inc. 

In that case the CFPB alleged that most ITT students could not afford to pay the full cost of tuition with federal loans. The difference between the amount received in student loans and the cost of tuition was known as the “tuition gap.” To close the tuition gap, ITT pushed no-interest loans called “Temporary Credit” onto students, which were due in nine months. “The Bureau alleg[ed] that ITT employed the Temporary Credit loans as an ‘entry point’ for ‘pushing’ students into taking out private loans …” As to the private loans, the CFPB alleged:

ITT Financial Aid staff coerced students into taking out loans that they did not want, did not understand, or did not even realize they were getting… ITT sought to have its students pay for the tuition gap with ostensible third-party loans because outside sources of payment could be booked as income to the company, improving its free cash flow and the appearance of its financial statements, and because outside sources of revenue helped ITT meet a requirement by the Department of Education that at least 10% of its revenue be derived from sources outside Title IV loans and grants.

ITT claimed that they were not a covered person under the CFPA as one of their defenses. The Court disagreed. It specifically found that their conduct surrounding the private loans could make them fall under the CFPA purview. To this point the Court held:

The Complaint includes allegations that ITT advised students on how to manage their debt to the school after having taken out Temporary Credit; this advice often channeled the students into the private loan programs … According to the Bureau, ITT completed nearly every step in the process of acquiring CUSO loans on the students’ behalf, including filling out the requisite forms (save signatures) and forwarding them to the lending credit union … At a minimum, we conclude that such conduct, if proven, would fall within the realm of “credit counseling” and “assisting a consumer with debt management.

Hospitals that nudge charity-care eligible patients into finance products are engaging in the same problematic behavior. As is shown in this comment, many hospitals advertise financing options on their website as a “financial assistance” option; they use very clear language to describe financing products and vague language to describe charity care; they make it difficult for both patients and staff to reach the financial assistance departments; they do not train staff on how charity care works or how patients can apply; and they make the charity care application process extremely difficult while making financing a breeze. Scores of low and middle income patients who are eligible for charity care, but are ignorant of its existence, turn to the hospital for help when they cannot pay the bill they were sent for a price they rarely agree to at the forefront. Many of these patients are pushed to finance their debt and away from charity care by hospital websites, phone infrastructures, application processes, and hospital employees.

The case against ITT also shows that hospitals meet the definition of a “service provider.” The CFPA defines “service provider” as follows:

(A)In general

The term “service provider” means any person that provides a material service to a covered person in connection with the offering or provision by such covered person of a consumer financial product or service, including a person that—

(i)participates in designing, operating, or maintaining the consumer financial product or service; or

(ii)processes transactions relating to the consumer financial product or service (other than unknowingly or incidentally transmitting or processing financial data in a manner that such data is undifferentiated from other types of data of the same form as the person transmits or processes).

In the ITT case the Court found that ITT could be a service provider if the CFPB proved its allegations that ITT:

Used Temporary Credit as a tool to pre-qualify students for private loans, that ITT developed the loans’ underwriting criteria, that it paid the credit union membership fees in the lead credit union on behalf of the students who took out the loans, and that it provided a stop-loss guarantee to the programs’ lenders – covering any losses from defaults exceeding 35% of participating students.

Many elements listed above are present in hospital contracts with third-party financing companies. While contracts between finance companies and hospitals are difficult to obtain, Kaiser Health News published three contracts between nonprofit and government hospitals and AccessOne. There are several similar terms. For example, the contract has addendums that appear to select a unique combination of different products by AccessOne that will be available to the hospital’s patients, and in one contract the hospital pays AccessOne a $75,000 “implementation payment” but in another it pays a “Servicing Fee” of 6% of all monies collected. The AccessOne contracts also call for non-performing accounts to be returned to the hospital. This is strong evidence that hospitals have negotiation power in how these products are specifically tailored at their hospital for their patients – in other words hospitals appear to have some authority over how these products are designed, operated, and maintained. 

In addition to or in lieu of the above recommendation, Dollar For also recommends the CFPB issue guidance or compliance bulletins outlining specific hospital conduct that would place a hospital under the purview of the CFPA.

Hospitals receive extremely valuable tax exemption in exchange for providing charity care to patients in-need. It is unjust and unlawful to allow a charity care policy to be no more than a .pdf buried on a website. Hospitals should be expected to be the pillars of the communities they claim to be. They should be seeking patients they can grant charity care to instead of begrudgingly giving it to those few who can get through the gauntlet. The CFPB currently has authority to act and it should. 

Treasury Specific Question #2 

RFI Question: Should a tax-exempt hospital’s signing patients up for medical payment products be considered similar to a tax-exempt hospital’s selling medical debt, such that the special rules that only exclude debt sales from being extraordinary collection actions if certain requirements are met would be applied to these payment products?

The vast majority of these payment products are debt sales and should already be treated as such under 501(r). In the vast majority of instances the hospital bills a patient for products and services rendered, and the right to collect that bill is transferred to a third-party financing company in exchange for the financing company paying the hospital money. If the bill is debt, which it is, then the hospital is selling the debt to the financing company. 

Treasury should not approach this issue to determine if these financing products should be treated as debt sales. It should recognize that they already are and always have been debt sales and it should enforce the law accordingly. Further, these sales violate 501(r). Hospitals are often not waiting 120 days from the date the patient is sent their first post-discharge bill as required by 26 CFR 501(r)-6(c)(3).

Treasury Specific Question #5 

RFI Question: What are the best practices for hospitals publishing and making patients aware of financial assistance programs (beyond compliance with a widely publicized requirements found in the section 501(r) regulations)?

Dollar For recommends regulations that require hospitals to find and screen patients as opposed to ending the hospital’s obligation at certain types of publishing and marketing of their policies.

Treasury should adopt charity care regulations that shift much of the burden from patients to learn about charity care to hospitals to screen patients for charity care. In other words, regulations should not focus on new ways to educate patients about charity care, they should focus on ways to get hospitals to find charity care eligible patients. 

Most patients fundamentally do not understand what charity care is. This is understandable as there really is nothing else in society quite like charity care. There are few, if any, other products and services for which you can receive a discount to reduce a bill you have already received. It is unlike how most discounts work, how rebates work, and any other general form of consumer benefit. Further, most fundamental concepts that charity care is built with such as the percentage of the federal poverty level are totally foreign to the everyday patient. People do not know where their household falls as a percentage of the poverty level. Even if patients are loosely familiar with the general concept of charity care they think that it only applies to the extremely poor. Many patients also think that charity care is a limited fund of government money that runs out. Many patients, for many different reasons, wrongfully assume they are not eligible for charity care or that the program will not actually help them. However, even if these hurdles to understanding could be addressed through different messaging requirements — this regulatory regime is unfair to patients. Low and middle-income patients simply do not have the bandwidth to learn about and get through the charity care gauntlet.

In the past decade studies have shown that being poor comes with so many mentally taxing everyday life compilations that it is “similar to a 13-point dip in IQ, or a loss of an entire night’s sleep.” Many patients who are eligible for charity care are dealing with many things on top of everyday financial pressures. They are trying to recover from an injury, battle a disease, comfort an upset newborn, or any number of mentally and emotionally draining things. It is simply more difficult and less fair to put the burden on these patients to learn about and acquire charity care as opposed to putting the burden on the hospital to find them and give them charity care.

At minimum Treasury should adopt regulations that: 1) add the referral of a bill to any debt collector or outside billing entity, regardless of whether the debt is assigned, sold, or any other designation, to the list of Extraordinary Collection Activities; and 2) it should adopt a requirement that before any patient can have their bill put on any sort of payment plan, whether in-house or through a third-party financing company, the patient must first be screened for charity care.

Treasury Specific Question #8 

RFI Question: Does the availability of medical payment products generally benefit the community or assist patients financially?

In very limited circumstances when all other forms of payment available to the patient such as Medicaid, charity care, etc. have been properly and fairly applied, there may be a small benefit to a few patients to offer zero interest long-term payment plans for any remaining balance. However, under no circumstances should this be considered a “community benefit” for the purpose of justifying a hospital’s tax exemption. 

There are already too many categories of community benefit that are either tenuously related to or completely untethered from the purpose of not-for-profit tax exemption. If a hospital employs a tool that allows it to get paid in full a price that is artificially and opaquely inflated to begin with, this is not a benefit to the community. 

Authors

Eli Rushbanks, General Counsel & Director of Policy, Dollar For
Jared Walker, Executive Director, Dollar For

Contributors

Elise Goldstein, Chief Operations Officer, Dollar For
Christy Snodgrass, Lead Policy Advocate, Dollar For
Erica Dowden, Lead Patient Advocate, Dollar For
Karen Nunez, Patient Advocate, Dollar For
Courtney Ulmer, Patient Advocate, Dollar For
Killeen McCans, Patient Advocate, Dollar For
Lin Navarro, Patient Advocate, Dollar For
Loanni Martinez, Patient Advocate, Dollar For
Lola Bajomo, Patient Advocate, Dollar For
Lindsey Muniak, Organizer, Debt Collective

Appendix A – Transcribed Call with University Health

S1: 00:00	Thank you for choosing University Health.
S2: 00:04	The patient business services and precision billing customer service department.
S3: 00:09	[foreign].
S2: 00:17	If this is a medical emergency, please hang up and dial 911. Please listen carefully as our menu options have changed.
S4: 00:27	If you are a CareLink member and would like to discuss your CareLink statement or make a payment, please press three.
S5: 00:37	If you are an attorney adjuster requesting medical records, press four.
S1: 00:42	If you’re wanting to make a payment for your University Health statement and pay by phone, please hold for the next available representative, or you can visit our website at myuhs.com. You can also email us with any questions at uhs.pbs@uhs-sa.com.
S2: 01:05	Otherwise, please stay on the line for the next available representative.
S1: 01:12	Please hold while your call is being connected to the next available representative. Your call may be recorded and may be monitored for quality assurance.
S6: 01:23	Thank you for calling University Health billing. This is REDACTED. How may I help you?
S7: 01:27	Hi, REDACTED. My name is REDACTED. I’m calling from Dollar For. We’re a nonprofit that helps folks apply to financial assistance programs at hospitals. And I’m calling on behalf of our client, REDACTED. I was hoping to get an update on a financial assistance application that we sent in on her behalf.
S6: 01:46	And where was that sent in to, ma’am?
S7: 01:48	That was submitted on June 20th via email, and let me take a look, to financial.assist@uhtx.com.
S6: 02:03	Okay. That’s a different department. I could give you the phone number to the financial department. That is 210-644-61– well, you know what? Financial assist. Hold on, hold on. Let me see if I have a phone number because I think that is something different.
	[silence]
S6: 02:38	Yeah. Because when you started to say that email, it sounded familiar. One moment.
	[silence]
S6: 02:57	Well, you know what? While I’m looking for this, what is the account number so I can pull up the account? Maybe it’s notated.
S7: 03:03	The account number is REDACTED.
S6: 03:10	Is that for UTHealth?
S7: 03:13	I have that she was seen at University Hospital in Texas.
S6: 03:18	Let me see. What is the patient’s name?
S7: 03:21	REDACTED.
	[silence]
S6: 03:35	All right. Let me see here.
	[silence]
S6: 04:06	I mean, I think this is for UT because that’s not coming up– when I put it in as the account number, it comes up a different patient. Yeah. Because the guarantor numbers for UTHealth start 3-something. Ours is 100. I even used it as like a– try to use it– looking it up as a medical record, didn’t come up, guarantor number, didn’t come up.
S7: 04:37	Okay. So is that–
S6: 04:37	But the account–
S7: 04:38	Is that a different health system?
S6: 04:41	So it is for physicians that are in our ER hospital. Or if they went to a specialist, the specialist doctor is a UT employee. Wherever they come get labs or x-rays done, the lab and x-ray tech are UT employees in our facility.
S7: 05:02	Let me take a look and just make sure I don’t have any other bills from her.
S6: 05:10	Was it for an ER visit?
S7: 05:12	I think it was. But even if that’s not her account number, could we look her up by name and date of birth?
S6: 05:22	Yes, ma’am.
S7: 05:23	Okay. So the last name is REDACTED.
S6: 05:36	And the date of birth?
S7: 05:38	Is REDACTED.
S6: 05:42	All right. REDACTED. All right. Let me see here.
	[silence]
S6: 06:12	Do you have an address for the patient?
S7: 06:14	Yeah. We have REDACTED.
S6: 06:21	Thank you. And is there a specific date of service, or?
S7: 06:28	We don’t collect dates of service exactly, but it looks like we have September and October of 2022. And we submitted that application, like I said, on June 20th.
S6: 06:51	All right. So I did pull up the patient, but I don’t have a September or October visit. The last time she was seen here was August of 2022.
S7: 07:00	That might be right, because we collect the bill date, not the date of service. So if it was a bill date of September 1st, it could be August.
S6: 07:10	All right. Let me see if there’s any notation here.
	[silence]
S6: 07:35	And you said it was sent in June?
S7: 07:38	Yes.
	[silence]
S6: 08:05	I do show a notation in May, where the patient called and said she’s getting help from an onsite agency, but I don’t show anything stating that we received documentations or forms or anything. I’m looking [inaudible]. I don’t see anything there either. Let me check something else here.
	[silence]
S6: 09:16	And you said the email was financial.assist@uhtx.com?
S7: 09:22	Yes.
S6: 09:24	I mean, I do show the email, but it doesn’t give me a department name or phone number.
	[silence]
S6: 09:52	Or an address or anything. It’s just an email in our system. And if I’m not mistaken, I think that’s the only thing that we have. Because I had a sheet where they sent us. And it was by management, but we asked for a phone number. It says, “We don’t have.” If I’m not mistaken, if I remember correctly, we have no phone number. It would just be email. You would just send an email to request a follow up. And I usually print all these things, and I can’t locate it at this time. I got pharmacy. I got client billing. Maybe I’m thinking of the client billing, but that’s a similar thing that they send us from management when in regards to client billing and it’s telling us that it needs to be forwarded to this email, but it doesn’t give us any phone number or address or anything or a contact person or nothing.
	[silence]
S6: 11:26	Yeah. This is something that I would have to present to management, but they won’t be back till next week. They’re on vacation, and then our supervisor is no longer with us, so. Is there a callback number that we could call you back?
S7: 11:45	Yes. You can give us a call back at REDACTED. And you’ll be able to leave a message on that line, and then one of us will be able to follow up with you.
S6: 11:57	All right. That was REDACTED?
S7: 12:02	REDACTED
S6: 12:08	Oh, REDACTED?
S7: 12:14	REDACTED.
S6: 12:17	REDACTED. All right. REDACTED. And you said your name was REDACTED?
S7: 12:24	Yes.
S6: 12:25	And what was the name of your organization again?
S7: 12:28	Dollar For. Dollar like a dollar bill, F-O-R.
S6: 12:36	Dollar For. All right. All right. I will notate the account with this information, but yeah, I’ll have to find out where this financial assist goes to, who handles this. Because yeah, I mean, it’s an email address and it just says alias financial.assist. Department, it doesn’t give me a department. You know what? Let me see if– hold on one moment. Let me see if I can– because one of our reps that used to be with us went to the financial department. I want to see if I can get a hold of her and see if she knows if they handled this email. Let me just push you on a brief hold.
S7: 13:23	That would be great. Thank you.
S6: 13:24	Yes, ma’am. [music]
	[silence]
S6: 15:34	Thank you for holding, ma’am. No, she did not pick up, so I’ll have to reach out to somebody else and see if we can find out who handles that website.
S7: 15:47	Okay. Awesome. Thank you so much for your help today. And I look forward to hearing back from you all.
S6: 15:52	Yes, ma’am.
S7: 15:53	All right. Thanks. Bye-bye.
S6: 15:55	Bye-bye.

Appendix B – Transcribed Call with Piedmont Health

S1: 00:00	Thank you for calling [inaudible] Healthcare Customer Solutions Center. If you are calling for emergency services, please hang up and dial 9-1-1. Your call may be monitored for quality assurance purposes. Did you know that Piedmont offers multiple ways to contact us for help? During business hours, you can contact us any time through your patient coportal, through MyChart, or by emailing your questions to customer service at Piedmont.org. Please listen carefully as our menu options have recently changed. Please choose from one of the following seven options. If you would like to pay your bill or discuss payment arrangement options, press one. If you are calling regarding an existing financial assistance application, press two. In order to serve you better, we would appreciate your participation in a brief survey after the call. To take the survey, please press one. All representatives are currently busy assisting other callers. Please stay on the line and your call will be answered in the order it was received.
	[music]
S1: 01:37	All representatives are currently busy assisting other callers. Please stay on the line and your call will be answered in the order it was received.
	[music]
S1: 02:15	Thank you for your patience. All representatives are still assisting other callers. Please continue to hold.
	[music]
S1: 03:22	We are currently experiencing high call volumes. Please continue to hold for the next available customer service representative or feel free to try your call again at a later time. All representatives are currently busy assisting other callers. Please stay on the line and your call will be answered in the order it was received.
	[music]
S1: 04:12	All representatives are currently busy assisting other callers. Please stay on the line and your call will be answered in the order it was received.
	[music]
S1: 04:49	Thank you for your patience. All representatives are still assisting other callers. Please continue to hold.
	[music]
S1: 05:56	All representatives are currently busy assisting other callers. Please stay on the line and your call will be answered in the order it was received.
	[music]
S2: 06:24	Thanks for calling Piedmont customer service. This is REDACTED. How can I help you?
S3: 06:31	Hi, REDACTED. My name is REDACTED. I’m with an organization called Dollar For. We’re a nonprofit, and we help patients apply for financial assistance. I just want to let you know that this call is being recorded. So we helped a patient, REDACTED, apply. And she was denied for being over income, and I just wanted to get some details about, I guess, how or why the patient was determined to be over income. The information that we have, and we have a lot of her income documents as well, reflect that she’s well below the threshold. And I was just trying to get some details on her account and her denial today. If you could help me with that?
S2: 07:15	You want information on what again? I’m sorry.
S3: 07:21	Oh, so this patient was denied financial assistance for being over the income threshold, and I’m trying to figure out how the hospital calculated her federal poverty level or just her income. According to the information that we have and the patient gave us, she’s well below the income threshold to qualify for assistance. And we did send an appeal letter so we sent all of this in writing to the hospital, and that was denied as well. And I’m just trying to get a little bit of an explanation as to why.
S2: 07:52	Okay. I can review that account if you have the account number or the guarantor number.
S3: 07:57	Yeah. The patient’s account number is REDACTED.
	[silence]
S2: 08:30	And you said, what was your name?
S3: 08:32	So my name is REDACTED. My last name is REDACTED. And the organization I’m with is Dollar For. The release of information that we sent was–
S2: 08:41	Dollar For?
S3: 08:43	Yes. So the release of information won’t have any person’s name specifically. It’ll say just Dollar For and its agent.
S2: 08:59	And you said you’re trying to find out why the application was denied.
S3: 09:02	Yes.
S2: 09:04	Let me see. I’ll see if I see something here. One second.
S3: 09:08	Okay.
	[silence]
S2: 10:50	Give me just a moment here.
	[silence]
S2: 13:17	Thanks so much for your patience. So I’m showing that that was, per the notes here on the account, that was denied here because she’s over the monthly income, the income property.
S3: 13:26	Okay. Do you know what the limit is exactly? What the threshold is?
S2: 13:35	That I’m not sure about. No, ma’am.
S3: 13:39	Okay. Does it show anything about how the patient’s income was totaled? What number do you have?
S2: 13:48	It doesn’t. No, ma’am.
S3: 13:51	Okay. Well, I guess just to clarify what I’m trying to get at is this patient makes way below the income threshold. So they’re a household of one. Y’all’s policy states that somebody can make up to 300% of the federal poverty level. So in order to qualify for assistance– so for a household of one, that figure of 300% of the federal poverty level is $43,740 a year in gross annual income. This patient submitted their tax return, the most recent one for 2022, and their total wages on their tax return is $29,728. They submitted their pay stubs. Their monthly income is about, let’s see here, $1,501 with 66 cents. So that’s monthly. I mean, their net earnings are about $18,000, but again, that figure on their tax return, even their total wages, $29,000 a year, is way below the $43,000 threshold. I don’t know if this account can be flagged for review or anything like that. We try to do that through the appeal process, but nothing came of it. And I don’t know. I don’t know if this was just a mistake on the hospital’s part, but I’m hoping to get some sort of explanation from the hospital as to why. There’s this kind of huge discrepancy in– and how the hospital might have come back [inaudible].
S2: 15:34	That was already denied. I’m not sure how that they come up with that decision here in that back end with financial assistance. Now, the only thing would be the patient would apply again.
S3: 15:51	Okay. All right. Okay. Well, you’re saying there’s no way to just sort of flag this to the, I don’t know, whoever the financial assistance department or whoever reviews this, that team? There’s no way to kind of just slide this account for review or some of the recording of this phone call or anything like that?
S2: 16:14	No, ma’am.
S3: 16:16	Okay. All right. Cool. Okay. Well, I guess I exhausted that. So I will try to help this patient reapply. But thank you so much for your help today.
S2: 16:29	No problem at all. And if you opt for that survey, please hold. If not, have a wonderful day.
S3: 16:33	All right. Thank you. Bye bye.

Appendix C – Transcribed Calls with Ochsner

First Call

S1: 00:01	Thank you for calling Ochsner patient accounts customer service. Your call is important to us. You may experience longer than normal wait times. Thank you for your patience as we help each caller. We value your feedback, so please remain on the line after you’ve been helped to answer a brief survey. All calls are recorded for quality and training purposes. Please press 1 if this is your first time calling about this request, or press 2 if you’ve called previously regarding this request. Here at Ochsner Health, patients are always our first priority. Skip the wait and connect with a live chat agent now. Simply log in to your MyOchsner account to begin a live chat session today. To make a payment, please press 1. To request an estimate before your service, please press 2. To schedule an appointment, please press 3. For a copy of an itemized bill, please press 4. For all other inquiries, or to speak with a customer service representative, please press 0.
	[silence]
S2: 01:21	Good afternoon. Thank you for choosing [inaudible]. My name is REDACTED. May I ask who I’m speaking with, please?
S3: 01:27	Hi, REDACTED. My name is REDACTED, and I’m calling from Dollar For. We are a nonprofit that helps folks apply to financial assistance programs at hospitals. I’m calling on behalf of our client, REDACTED. And just so you know, you’re on a recorded line with me. I have a medical record number and a date of birth. However is easiest for you to look her up, just let me know.
S2: 01:50	What’s the last name? Spell it for me.
S3: 01:52	REDACTED.
S2: 02:11	And can you verify the date of birth, address, and phone number?
S3: 02:14	Yeah. The date of birth is REDACTED, address is REDACTED, and phone number is REDACTED.
S2: 02:31	Thank you so much for verifying the information. And how can I help you today?
S3: 02:35	Yeah. So we submitted a financial assistance application on July 12th via email for REDACTED, and we heard back on July 18th that that application was denied because the patient has no balance. But she does have a balance from Ochsner Health. And [crosstalk]–
S2: 03:00	She has a zero balance on her account. Which hospital? Because she has a zero balance on her account.
S3: 03:06	She told us it was Ochsner Medical Center. [crosstalk]–
S2: 03:12	So it could depend on the hospital, because we don’t have all– even though it’s a hospital of Ochsner– we don’t have [inaudible] memorial accounts. We don’t have [inaudible]. We don’t have Lafayette. We don’t have– it’s another one that we don’t have. If it’s one of those hospitals, they have their own billing, which they have their own number. From what I’m seeing, she doesn’t have a balance on this account with us.
S3: 03:40	Interesting. So–
S2: 03:40	And the last time she was seen, it looks like was– with us, the last time she was seen–looks like it was back in March REDACTED. And looks like that claim was paid by Blue Cross/Blue Shield, and she doesn’t have a balance with us at all.
S3: 04:02	So what I’m seeing on my end is– I have a bill in front of me. It says, “Date of service, March REDACTED, 2023.” Med surg charges– the insurance paid $33,000, but she still owes $4,082.
S2: 04:24	Again, could you verify which hospital [inaudible] with the patient? That way I can see– because I’m not seeing a account. I’m not seeing a balance on her account.
S3: 04:34	Sure. All I’m seeing is Ochsner Medical Center under the hospital services. I do have [crosstalk]–
S2: 04:42	Does it list the hospital?
S3: 04:44	It doesn’t list the hospital anywhere on the bill that I’m seeing. I have a guarantor ID and a specific account number, if those would be helpful in trying to locate it.
S2: 04:55	Not the account number. The guarantor ID number would help.
S3: 04:58	Okay. That is REDACTED.
S2: 05:07	Yes, ma’am. That’s the account that I’m looking at, and she has a zero balance.
S3: 05:12	Okay. Now, would it be possible that that balance had been sent to ClearBalance?
S2: 05:20	I can double-check as well. Give me one second.
S3: 05:23	Thank you.
	[silence]
S2: 05:34	Let’s see.
	[silence]
S2: 05:50	Yes. It was sent to ClearBalance, so they have the account now.
S3: 05:54	Okay. So since she applied within 240 days, I do believe that the hospital is still required to review that financial assistance application, and if so, hold the account back and issue her a refund, or pull the account back from ClearBalance, since you all sent her to ClearBalance originally.
S2: 06:21	Okay. Can I place you on a brief hold while I find the information out?
S3: 06:25	Yeah. That’d be great. Thanks.
S2: 06:27	Hold on for me.
S1: 06:31	[Virus?] in our communities. We all have the power to make a difference. Every person who gets vaccinated brings us closer to getting our lives back to normal and helps keep our loved ones healthy and safe. For up-to-date information on COVID-19 vaccines, please visit ochsner.org/vaccine. Have you heard the news? For the 10th year in a row Ochsner Medical Center has been ranked the number one hospital in Louisiana and one of the nation’s top 35 in neurology and neurosurgery by US News and World Report. In 2020 we healed more than 900,000 people from across the globe, providing the latest medical breakthroughs and therapies across 90 specialties and subspecialties. You are the reason for our team’s relentless pursuit of excellence, and we will continue to strive to give our community and patients the best care possible. For more information visit ochsner.org. As part of Ochsner Health’s continued commitment to improving price transparency and empowering patients through better access to price information, you can now create a personalized estimate online for over 300 Ochsner services through MyOchsner or on our website. For more information, please visit ochsner.org/billingestimates. With MyOchsner we make it easy for you to schedule an appointment, communicate with your providers, view test results, refill prescriptions, and more right from your phone. Log in or sign up for an account today, and you’ll have every aspect of your care at your fingertips. Visit my.ochsner.org and download the app to start managing your health online today.
S1: 08:30	We are proud to announce that Ochsner Hospital for Children is the number one children’s hospital in Louisiana. We have been named best children’s hospital by US News and World Report, and are the only ranked children’s hospital in Louisiana for five years in a row. Ochsner Hospital for Children has offered exceptional pediatric care for more than 75 years. We offer the only pediatric heart and liver transplant program in the state, serving over 76,000 children every year. Our team is made up of more than 150 physicians, specializing in more than 30 pediatric specialties and subspecialties. To learn more visit ochsner.org/forchildren. Calling to schedule an appointment? Did you know you can do this online through chat with a live team member on ochsner.org? In addition to scheduling an appointment, you can also receive assistance with billing, finding a location or physician, as well as getting answers to general questions. This is all available Monday through Friday, 8 AM through 5 PM, and 24/7.
S2: 09:40	Yes, ma’am. Please continue to hold while I find out more information.
S3: 09:43	Yeah. Thank you.
S2: 09:45	Okay. Hold on.
S1: 09:47	[Children’s?] hospital in Louisiana for five years in a row. Ochsner Hospital for Children has offered exceptional pediatric care for more than 75 years. We offer the only pediatric heart and liver transplant program in the state, serving over 76,000 children every year. Our team is made up of more than 150 physicians, specializing in more than 30 pediatric specialties and subspecialties. To learn more, visit ochsner.org/forchildren. Calling to schedule an appointment? Did you know you can do this online through chat with a live team member on ochsner.org? In addition to scheduling an appointment, you can also receive assistance with billing, finding a location or physician, as well as getting answers to general questions. This is all available Monday through Friday, 8 AM through 5 PM, and 24/7 through the Ochsner chatbot. Skip the wait and visit ochsner.org to start chatting now with one of our team members.
	[silence]
S1: 11:07	[Ochsner Health?] is now administering the Pfizer COVID-19 vaccine for children ages 5 to 11 at limited locations across our region, with convenient weekday and weekend hours. Children under age 18 require consent by a parent or legal guardian before vaccination will be given. Ochsner and Ochsner Hospital for Children fully support and highly encourage vaccination of all eligible children, adolescents, and adults. To learn more or view vaccine locations and hours, please visit ochsner.org/vaccineinfo. Ochsner Health is committed to protecting our patients and staff from COVID-19. Controlling a pandemic [requires using?] every tool available. Just like wearing masks, social distancing and washing your hands, getting the COVID-19 vaccine will help stop the spread of the virus in our communities. We all have the power to make a difference. Every person who gets vaccinated–
S2: 12:12	Okay. Thank you so much for holding. So what I could do– I’ll have to send it to upper management to get it approved to pull from ClearBalance to be back on the patient account. It could take about 7 to 14 business days to reflect that balance back on the account. And once the balance is reflected, then the patient can call to reapply for financial assistance. So if she hasn’t heard anything in two weeks, or that she see a change coming from a zero balance back to the payment– the account that she sent over to them, she can call back and reapply once the balance is put back on her account, which could take about 7 to 14 business days, because I have to send it to management approval first.
S3: 12:58	Okay. Awesome. I will email the patient and let her know that is what’s happening. And then we will resubmit that application in two weeks.
S2: 13:09	All righty. Anything else I can assist you with today?
S3: 13:12	That’s all I have. Thanks.
S2: 13:14	All right. You have a great day. Thank you for [inaudible].
S3: 13:16	You too. Bye-bye.

Second Call

S1: 00:01	Thank you for calling Ochsner Patient Accounts Customer Service. Your call is important to us. You may experience longer than normal times. Thank you for your patience as we help each caller. We value your feedback, so please remain on the line after you’ve been helped to answer a brief survey. All calls are recorded for quality and training purposes. Please press 1 if this is your first time calling about this request, or press 2 if you’ve called previously regarding this request. Here at Ochsner Health, patients are always our first priority. Skip through and connect with a live chat agent now. Simply log in to your MyOchsner account to begin a live chat session today. To make a payment, please press 1. [music] When you receive all your care at Ochsner, you can rely on a care team that coordinates care on your behalf. Our Ochsner providers work collaboratively from a single medical record so they more fully understand your health history and can provide a personalized approach. Additionally, because all Ochsner providers have access to your complete medical file, you won’t need repeat tests or unnecessary procedures and you can focus on getting healthy faster. Schedule now at ochsner.org/appointments or by going to my.ochsner.org.
S2: 01:29	With MyOchsner, we make it easy for you to schedule an appointment, communicate with your providers, view test results, refill prescriptions, and more, right from your phone. Log in or sign up for an account today, and you’ll have every aspect of your care at your fingertips. Visit my.ochsner.org and download the app to start managing your health online today.
S1: 01:51	We aim to offer convenience when you need to be seen. At Ochsner, appointments with a primary care provider are available at a time that works for you. You’ll find both early and late extended-hour appointments as well as weekend options at Ochsner. And with Ochsner Urgent Care around the region, you will have access to immediate quality care that gets you back on your feet faster. We’re relentless about providing the care you need. Visit ochsner.org/appointments to schedule now or to find an urgent care location near you.
S2: 02:27	Are you calling to schedule an appointment? Did you know that you can schedule your appointment online for more than 50 specialties? Schedule now at ochsner.org/appointments. If you have a MyOchsner account, you can schedule quickly and easily with any of your regular physicians.
S1: 02:45	Our primary care doctors don’t just see you when you’re sick. They work hard to keep you well. At Ochsner, your primary care team serves as your healthcare quarterback and monitors your care to ensure that everything from specialist treatments to routine screenings build one complete picture. That way, they can guide you through changes or issues so they’re addressed quickly. If you don’t have a primary care doctor, schedule a primary care appointment now to get that support in place. Simply visit ochsner.org/appointments.
S2: 03:19	Ochsner Pharmacy & Wellness is here to help extend the care Ochsner provides for patients. We offer home delivery, bedside delivery, automatic prescription refills, on-site immunizations, and more. With more than eight locations serving New Orleans, Baton Rouge, and surrounding areas, Ochsner is committed to meeting your needs conveniently. Download the Ochsner Pharmacy app, request refills in your MyOchsner account, or visit ochsnerpharmacy.com for details and locations. That’s innovating healthcare. Ochsner Pharmacy & Wellness is here to help extend the care Ochsner provides for patients. We offer home delivery, bedside delivery, automatic prescription refills, on-site immunizations, and more. With more than eight locations serving New Orleans, Baton Rouge, and surrounding areas, Ochsner is committed to meeting your needs conveniently. Download the Ochsner Pharmacy app, request refills in your MyOchsner account, or visit ochsnerpharmacy.com for details and locations. That’s innovating healthcare. With MyOchsner, we make it easy for you to schedule an appointment, communicate with your providers, view test results, refill prescriptions, and more, right from your phone. Log in or sign up for an account today, and you’ll have every aspect of your care at your fingertips. Visit my.ochsner.org and download the app to start managing your health online today.
S1: 04:54	We aim to offer convenience when you need to be seen. At Ochsner, appointments with a primary care provider are available at a time that works for you. You’ll find both early and late extended-hour appointments as well as weekend options at Ochsner. And with Ochsner Urgent Care around the region, you will have access to immediate quality care that gets you back on your feet faster. We’re relentless about providing the care you need. Visit ochsner.org/appointments to schedule now or to find an urgent care location near you.
S2: 05:30	Are you calling to schedule an appointment? Did you know that you can schedule your appointment online for more than 50 specialties? Schedule now at ochsner.org/appointments. If you have a MyOchsner account, you can schedule quickly and easily with any of your regular physicians.
S1: 05:48	Our primary care doctors don’t just see you when you’re sick. They work hard to keep you well. At Ochsner, your primary care team serves as your healthcare quarterback and monitors your care to ensure that everything from specialist treatments to routine screenings build one complete picture. That way, they can guide you through changes or issues so they’re addressed quickly. If you don’t have a primary care doctor, schedule a primary care appointment now to get that support in place. Simply visit ochsner.org/appointments.
S2: 06:23	Ochsner Pharmacy & Wellness is here to help extend the care Ochsner provides for patients. We offer home delivery, bedside delivery, automatic prescription refills, on-site immunizations, and more.
S3: 06:43	Good afternoon. Thank you for choosing Patient Accounts Customer Service. My name is REDACTED. May I ask who I’m speaking with, please?
S4: 06:49	Hi, REDACTED. My name is REDACTED, and I’m calling from Dollar For. We are a nonprofit organization that helps folks apply to financial assistance programs at hospitals. You are on a recorded line with me. I called and spoke with one of your other representatives, REDACTED, on August 4th about our client REDACTED, and she confirmed that she would send a request to pull this patient’s balance from ClearBalance so that they could apply for financial assistance. So I was hoping to check in on that and see if the balance had been pulled.
S3: 07:26	Okay, ma’am. We cannot pull the balance from ClearBalance to place it on financial assistance.
S4: 07:34	Interesting. That is what the representative told me the last time I spoke to them. Could we take a look at this account and see what the status of it is?
S3: 07:42	Yeah, I can take a look, but I can definitely know that we can’t take [your?] collections to place it on there. That’s not true information. I apologize. What’s the patient’s first name?
S4: 07:51	The patient’s first name is REDACTED.
S3: 07:56	Last name?
S4: 07:57	REDACTED.
S3: 08:07	Her date of birth and address?
S4: 08:09	Date of birth is REDACTED, and the address is REDACTED.
S3: 08:21	Okay. And this is the patient’s current address, right?
S4: 08:27	That is the one that we have. We may have another one on file. I could look.
S3: 08:31	That’s what we have on file too. And also, we don’t service Houston, Texas residents. We service them, but they won’t be eligible for any type of financial assistance if they’re living in the State of Texas.
S4: 08:45	Okay. I think that she was living in Louisiana at the time, potentially. She had to move to Houston in order to get care at MD Anderson.
S3: 08:56	Okay. All right. So I don’t show anything. You say you called, but I don’t show anything of that. I do show on July 17th, the financial assistance was denied, but I don’t show anything else.
S4: 09:16	Yeah. The last time I spoke to a representative, she said the financial assistance was denied because the account had a balance of 0 because it was put on ClearBalance. Now, ClearBalance, to my understanding, is not a collections agency. It’s a care credit card.
S3: 09:32	No, it’s not a care credit card.
S4: 09:35	Okay. [Excuse me?].
S3: 09:35	[CSI?] is a third-party payment plan. It’s a payment plan where it starts from a year up until 24 months, patients that have large balances. Ochsner pays the interest fees on it. The patient doesn’t pay interest fees. So that’s not a care credit.
S4: 09:56	Okay. Interesting. I will bring this up to our team to find the best next steps for this patient. Thank you for your help today.
S3: 10:05	You’re very welcome. And good luck with everything. Sorry I can’t be more of assistance.
S4: 10:10	That’s all right. Have a nice day. Bye-bye.
S3: 10:12	You too. Bye-bye.

Appendix D – Transcribed Call with Orlando Health

S1: 00:00	Thank you for calling the Orlando Health Patient Business Services. All of our calls are recorded for quality assurance purposes. We are currently aware of a technical issue surrounding our MyChart portal payment option. If you are calling in regards to this and wish to make a payment, please follow the appropriate steps to use our secure automated payment system. Thank you. If you are calling from an insurance company, please press one. If you are calling from an attorney’s office, please press two. If you are calling in to make a payment, please press three, or you can go online at Orlandohealth.com in order to make your payment. If you are a patient or guardian of a patient, please press four or remain on the line for the next available agent. Thank you.
S2: 00:51	Thank you for calling Orlando Health Patient Business Services. All calls may be monitored or recorded for quality assurance purposes. Can I please have the account [inaudible]?
S3: 01:01	Hi, my name is REDACTED and I’m calling from an organization called Dollar For that helps folks apply for financial assistance, and just so you know this call is recorded on our end as well. I was just calling for an update on a client of ours and their financial assistance application. So I don’t think I actually have his account number, but I can give other identifying features.
S2: 01:28	Okay. Can you provide the first and last name?
S3: 01:31	Yeah. It’s REDACTED. The last name is REDACTED.
S2: 01:49	And the first name is what?
S3: 01:53	Is REDACTED.
S2: 02:02	Okay. And for security purposes, can you please provide the date of birth as well as address?
S3: 02:10	Yes. The date of birth is REDACTED. And the address is REDACTED.
S2: 02:21	Okay. Is there a phone number that she can be reached out?
S3: 02:25	Yeah. Their phone number is REDACTED.
S2: 02:37	You said REDACTED?
S3: 02:41	Mm-hmm.
S2: 02:43	REDACTED?
S3: 02:44	REDACTED.
S2: 03:07	Yeah. Okay. It looks like the financial assistance that she applied for for March 28th, it was denied over income threshold. Basically, I guess the income surpassed was over the threshold of the requirement for assistance.
S3: 03:27	Okay. So can you tell me what you had their household income recorded as?
S2: 03:36	According to what I’m looking at here, looks like the total that they’re bringing in gross annual income is $36,000.
S3: 04:08	Okay. And so if they’re making $36,000 annually and that’s a household of four people, that’s only on–
S2: 04:17	[inaudible] the same.
S3: 04:20	What was that?
S2: 04:21	It’s saying it’s no dependents. Well, it’s actually saying no dependents and it’s just one person.
S3: 04:26	That is not the information we have, actually. We have that there is a spouse and two children. Or there’s a spouse and a child.
S2: 04:33	[inaudible]. But that’s not listed on there.
S3: 04:38	Okay. Let’s see. I have their application here as well. [inaudible] application. So I have a copy of the financial statement and hospital application that we sent to you. And it has household and family information. And it has a child. Yeah. I think it has two children listed on it.
	[silence]
S2: 05:25	Okay. So is there any way they can update the information on file?
S3: 05:38	We can work on that. I guess my question would be then where are you getting your information? Because I have a copy of the application that we sent to you. It says guarantor financial statement for Orlando Health at the top. And it does have four household members listed and it has two children on it.
S2: 06:00	But it’s saying that employee or the person is full time.
	[silence]
S2: 06:23	And it looks like your expenses is lower than the amount that’s bringing in. And she’s got assets. There’s a lot of the– I guess, they expect [to see?] of an income.
S3: 06:47	Like her checking account asset? So even though they would be at 120% of the federal poverty level with their income and household size, that doesn’t count?
S2: 07:00	Well, the household size over here is just one person and that’s $36,000. To be honest with you, if I was one person bringing in $36,000 a year, that’d probably be a pretty nice line to be at for one person.
S3: 07:21	Yeah. No, I agree with you, but this is for a family of four. And we can resubmit an application. I’m just not sure why you have recorded that it is a household of one because I have the application that we sent to you and it has two children on it.
S2: 07:40	Well, it’s not on this one. I apologize.
S3: 07:45	Okay. And let me just see when this was submitted. Okay. So we submitted an application on April 11th. Is that the one that you’re seeing?
S2: 08:12	No, it’s not unfortunately.
S3: 08:15	Okay. Can you tell me when the one you were seeing was received?
S2: 08:21	This one was received March 28.
S3: 08:25	March 28th. Okay. I will make sure that we get an updated application to you that accurately reflects the size of the house.
S2: 08:44	Please.
S3: 08:46	All right. Thank you very much. Have a nice day.
S2: 08:48	You too.
S3: 08:49	Bye.

Appendix E – Transcribed Call with Jackson Health

S1: 00:00	Thank you for calling the Jackson Eligibility Management Department at Jackson Health System. For instructions in English, please press one. This call may be recorded or monitored for quality assurance purposes. Please stay on the line to speak to a representative. We value your opinion about your experience with us today. After you speak to a representative, please stay on the line and an optional survey will be available that will take less than two minutes to complete. Thank you. Thank you for calling Jackson Health System. We understand that your time is precious, and we appreciate your holding. Your call is very important to us, and we’ll be with you in just a moment. [music]
S2: 01:03	Thank you for calling Jackson Health System. How may I assist you?
S3: 01:07	Hi, my name is REDACTED. I’m calling with Dollar For. We’re an organization that helps folks apply for financial assistance. And just so you know, you’re on a recorded line. I was calling to ask about a status update for a client who we prepared an application for. And you should have [crosstalk] on file for him.
S2: 01:29	Okay. So let me explain– give you a little caveat. I’ll be glad to look, but most likely I’m going to have to send a message because we schedule the initial appointment. We don’t really know until and unless we see a change on the patient’s chart, if they’ve had the J card before. These people only communicate through email. So we advise– well, I advise the patient to make sure they check their email because if they need any more documents, they’ll correspond to that way, but I will be glad to send a message to have a specialist go ahead and give the patient a call back. Usually, they call back because I haven’t gotten any complaints that they don’t. May I have the patient’s last name?
S3: 02:14	Yeah. It’s REDACTED. It’s REDACTED.
S2: 02:28	Okay. And may I have the patient’s first name?
S3: 02:31	Alexander. REDACTED– birthday is.
S2: 02:39	Oh, I’m sorry.
S3: 02:41	That’s okay. If you have REDACTED down, we don’t have to spell it. And then his birthday is REDACTED.
S2: 02:54	Okay. And do you have the last four of the patient’s social?
S3: 02:59	I don’t have his social. I could give you a phone number or his address that the bill goes to.
S2: 03:03	Okay. Okay. What is this current mailing address?
S3: 03:07	REDACTED.
S2: 03:13	Okay. And may I have the patient’s phone number?
S3: 03:15	REDACTED.
S2: 03:21	Okay. All right. Let’s see what’s going on. Okay. So it’s still self-pay. Let me see something. So he had his– oh, he should have been– that’s improper English. He should have had a response by now. Has he been checking his email?
S3: 03:41	We have not received correspondence, but we’re helping him with this case. So since you have a release of information on file, you should be able to tell me if it was approved or denied or if he needs more paperwork.
S2: 03:53	Yeah, we don’t. Like I said, before we were scheduling, they don’t share that pertinent information. We don’t even have access to their database. Like I said, we schedule the initial appointment and then they correspond through the email if they need any documents. So usually we’re supposed to tell the patient that please check your email because if they’re missing anything, they’re going to let you know through that email.
S3: 04:16	Okay. Is there anyone that I could be transferred to? Because we–
S2: 04:21	No. They don’t have a phone number. I would have to send a message over for them to have them give you a call back.
S3: 04:29	That would be great because we emailed them back in May, and we have not heard a response.
S2: 04:35	Okay. So did he ever check his email?
S3: 04:39	I’m not sure. And I’m not sure what the patient’s access to email is like. I’ll definitely reach out to him as well and ask if he has an update for us, but if you could maybe send them a note and ask them to send an update to debtforgiveness@dollarfor.org?
S2: 05:01	Give me one moment. Is he getting this out– I want to find out. Is he getting this card to pay off debts or is he getting it for– because this card is only primarily for outpatient appointments?
S3: 05:17	Well, so we prepared a financial assistance application because he had an outstanding bill of $14,748.55 cents. So yes–
S2: 05:29	This card would not help pay that debt though.
S3: 05:33	Okay. It’s mostly outpatient services?
S2: 05:37	Yes, ma’am. If the patient wanted to go to primary care physician or if he wanted to, say, get his teeth clean or a teeth pull, if he had a specialty doctor that he was going to. But for past due bills, they do not use this card for that. This is not an insurance card. It’s just a card to say, hey, we want to help you pay the bill. They’ll pay the full bill depending on the patient’s income or the documents that are provided. Or they will tell them how much of a portion they need to pay.
S3: 06:17	Yeah. Well, so is Jackson Memorial Hospital a nonprofit hospital?
S2: 06:24	Yes, but they don’t help pay. If a person has a pass through bill, I had to explain this to someone else. They weren’t happy. I try to explain as much as possible when scheduling my appointment for the patient so that they were on the same page. So they won’t think, “Hey, I got a pass through bill. They’re going to help me pay for it.” No, they’re not. They’re only helping you for your appointment– they’re only helping you for your appointment. If you have an appointment for a primary care physician, or say if it was a woman she needed to pay for her OB appointment and she has no insurance, they’ll look at the income and determine the type of J card they’re going to give the patients to help them to pay for their appointments.
S3: 07:02	Yeah, I definitely understand that that’s your hospital’s policy, but according to the Affordable Care Act, it’s a legal requirement for every hospital to have a charity care program for folks with outstanding medical bills. And so this would be covered under that policy. And that’s what we’re trying to help this patient apply for. We’re a national nonprofit.
S2: 07:20	You definitely need to talk to these people because we have never heard that they have to do that.
S3: 07:26	Okay. That sounds good. Thank you so much for your help today.
S2: 07:32	Okay. Is there anything else I can assist you with?
S3: 07:34	No, that’s all I have. Thank you.
S2: 07:37	Thank you for calling Jackson Health System.

Appendix F – Transcribed Call with Ascension Seton

S1: 00:01	Thank you for calling Ascension Seton Medical Center Austin at 1201 West 38th street, Zip code 78705. If you would like patient information, press two. If you need an operator, press zero at any time. If you know your party’s five digit extension, press one. If you remain on the line, your call will be transferred to the operator. Good afternoon. Thank you for calling. Your call will be answered by the first available operator. You are caller number three in queue. Calls are answered in the order that they are received. [music]
S2: 01:48	Thank you for calling Seton Medical Center Austin. This is REDACTED. How can I help you?
S3: 01:52	Hi, REDACTED. Can I speak to your financial assistance or billing department?
S2: 01:57	Of course. I’d be happy to. Is this for billing for the facility providers or do you know if it was from a specific department like US acute care, tri-county practice, or AMG?
S3: 02:14	I don’t think I have a copy of the bill in front of me. So I would just say it’s probably the hospital bill.
S2: 02:23	Of course, I’d be happy to connect you.
S3: 02:25	Great. Thanks.
S2: 02:26	All right. And when I do connect you over, since you don’t have a copy of that bill and you don’t have the account number correct, if you want to speak with one of those representatives, it’s going to be one of the last options. It’s going to ask for an account number. Just enter zero followed by pound, and confirm that is correct. That way it connects you over through to one of the representatives.
S3: 02:49	Okay. Great. Thanks.
S2: 02:51	You’re welcome. All right. Connecting you over to billing. Have a great day.
S3: 02:57	Thanks.
S1: 03:04	Thank you for calling Ascension Seton Customer Service. All calls are monitored and are recorded. To continue in English, please press one. [foreign]. Please be aware that the following menu options may have changed. To make a payment over the phone, please press one. If you would like to provide an insurance update, please press two. To request an itemized statement, please press three. To request a charity application in the mail, please press four. If you are calling from an insurance company or on behalf of an insurance company or affiliate, please press five. If you are calling for a price estimate, please press six. If you need to speak with one of our customer service representatives, please press seven. To repeat these menu options– please enter the account number found on your most recent statement sent in the mail followed by pound. You have entered zero. If this is correct, press one for yes or two to reenter. All of our agents are currently assisting patients. If you’d like us to hold your spot in line and call you back when the next representative is available, press one now. Otherwise, please continue holding for the next available–
S4: 04:32	Hi. Thank you for calling Ascension Customer Service. My name is REDACTED. Can I have your account number, please?
S3: 04:39	Hi. My name is REDACTED. I’m calling from Dollar For. We are a nonprofit that helps folks supply for financial assistance. Just so you know, this is a recorded line. I do not have an account number, but I could give you the patient’s first, last name, date of birth, all that good stuff.
S4: 04:56	Thank you very much. Just to confirm, your name is REDACTED. Is that correct?
S3: 05:00	It’s REDACTED.
S4: 05:06	REDACTED.
S3: 05:08	Yes.
S4: 05:08	That’s a beautiful name. Thank you very much. Can I ask for your full name so that I can put you in my system, please REDACTED?
S3: 05:14	Yes. My last name is REDACTED, REDACTED.
S4: 05:23	Thank you very much. And from what company that you’re in right now, REDACTED? Sorry, they didn’t get that one.
S3: 05:28	Dollar For. Dollar like a dollar bill space F-O-R.
S4: 05:35	Dollar For. Is this an insurance provider or a law firm office?
S3: 05:43	No, neither of those. We’re a nonprofit that helps folks apply for financial assistance.
S4: 05:51	Okay. Thank you very much for that one. Do you have right now the phone number of the patient so that I can check here in my system?
S3: 05:57	Yes. That’s REDACTED.
S4: 06:07	Just to confirm I got it right, it’s REDACTED. Is that correct?
S3: 06:13	Yes.
S4: 06:14	Thank you. Give me a second here. Let me check if I can pull up an account for you. Bear with me, REDACTED. Well, just to confirm as myself well, can I ask for the facility or the hospital that the patient go through?
S3: 06:37	Yeah, Ascension Seton Medical Center Austin.
S4: 06:42	Austin. Can I ask for the first name of the patient, please?
S3: 06:47	Yeah, that’s REDACTED?
S4: 06:56	REDACTED. I’m sorry.
S3: 06:59	REDACTED, as in REDACTED.
S4: 07:16	Can you spell it out for me the first name? Please the first.
S3: 07:19	Yeah. REDACTED.
S4: 07:32	Thank you very much for that one. Let me check this one for you. Give me a second here.
S3: 07:34	Thanks.
S4: 07:38	You’re welcome. So let’s check in for the phone number. And first thing here or last thing. Just give me a second here. Thank you. And this for a future service or a past service?
S3: 08:07	Past service.
S4: 08:10	Past service. Can I ask, are you looking for a position bill or a hospital bill?
S3: 08:16	With the balance, it is probably a combination of both. It looks like they are from potentially around February and March of 2023. But [crosstalk] application on July 7th, via mail. So I’m hoping to check and see if that has been received.
S4: 08:40	Let me check that for you first. If I have the records for the patient’s name REDACTED, okay?
S3: 08:46	Okay. Thanks.
S4: 08:47	One moment, please, REDACTED. You’re welcome. REDACTED. Okay. It seems that I can not find a record using the phone number of REDACTED. Let me check for the first name and last name. Bear with me. You’re welcome. It’s loading. And do you know the full address on the account, please?
S3: 09:42	The one that I have is REDACTED.
S4: 09:52	Thank you very much. And can you confirm the date of birth of the patient, please?
S3: 09:57	Yes. That is REDACTED.
S4: 10:03	Thank you very much for that one. It seems that I can now see a record named REDACTED. Just give me a second here. Thank you. So you were calling for today because you wanted to see or check if the payment goes through. Is that correct?
S3: 10:28	Not the payment. The application for financial assistance.
S4: 10:33	The application for the financial assistance. Just give me a second here. Let me check that one for you.
S3: 10:42	Thank you.
S4: 10:43	You’re welcome.
	[silence]
S4: 11:06	Okay. Very cool. I see my notes here, the notes.
	[silence]
S4: 12:14	Okay. Sorry for the long wait here, REDACTED. Thank you. So upon tracking here, it seems that I cannot see a record that the patient is currently under the charity form, or if the application form already go through to our system. Can they ask for the text number or something, what method did you use to send us the application form or something like the application financial assistance?
S3: 12:40	Yeah. We mailed that on July 7th, 2023.
S4: 12:46	July 7th, 2023. Let me check all the documents here in my system. Just bear with me here, REDACTED. It’s the big one. If the specific document already go through, one moment please. Thank you. I’m just going to put you and hold for at least a minute or two so that I can fully check, okay?
S3: 13:33	Mm-hmm.
S4: 13:33	One moment. Thank you, REDACTED.
	[silence]
S4: 16:15	Hello. Sorry for the long wait here, REDACTED. Thank you very much for patiently waiting. So upon checking here in my system, I try to double check all the documents associated with the account or the account numbers. Well, but unfortunately, I can see a document for this application form that you are mentioning for the financial assistance now. So have you tried to send this one in the email address or e-fax number that we have in our system?
S3: 16:47	Let me see what we did originally, because we mailed it to the mailing address on the application. There’s a PO box in Dallas, and a PO box in Indianapolis. That, we would have sent it to. And then let’s see, before that, we faxed that to 512-406-0714.
S4: 17:21	0714.
S3: 17:24	Do you have a better place for me to email or track that? I can get it resubmitted today.
S4: 17:32	Sure. I have here the email address that you can send this application form. And just to confirm as well, out of curiosity, is this an application form that the patient already applied for? Or is the patient trying to apply for financial assistance?
S3: 17:50	Yes, the patient is trying to apply for financial assistance.
S4: 17:55	Okay. You can send the document to us, by the way.
S3: 17:59	Okay.
S4: 18:02	Tell me if you’re ready.
S3: 18:03	I’m ready.
S4: 18:06	Wonderful. It’s support documents, @ symbol, R for Romeo, number one, R for Romeo again, C for Charlie, M for Mike, dot com.
S3: 18:37	Okay. We will get that resubmitted today and maybe the mail application will also be processed soon. Thanks so much for your help today.
S4: 18:45	Wonderful. And by the way, the document will be written in our system or reflected in our system in the next 7 to 10 business days. Okay. It’d be processed by one of our back-end office [inaudible].
S3: 18:56	Okay. Great. Thanks so much. I will make a task.
S4: 19:00	You’re welcome. Goodbye for now.
S3: 19:02	Bye.