Payment Assurance Discount Program
This program is designed to curb out of pocket costs to a more affordable amount for CT, MRI, and MRA scans by limiting costs to $500 per study.
Read below to learn more.
Patient out of pocket liability for outpatient CT’s, MRA’s, and MRI’s that are performed in outpatient diagnostic imaging departments and that are not performed as part of an emergency room visit, observation, outpatient surgery, inpatient stay or as part of another more complex service performed on the same day, shall be capped at five hundred dollars ($500.00) per CT, MRA, or MRI for each CT’s and MRI’s provided on the same date.
Any contrast or dye provided as a necessary component of the capped CT, MRA, or MRI shall also be included in the capped amount; however, any other tests, studies, or services performed on the same day shall not be included in the capped amount.
Patient out of pocket expenses for services that are not capped by the Payment Assurance Discount remain eligible for other Valley Health patient discounts, including the 10% pre-payment discount, the 5% prompt-payment, and 15% employee discounts.
Services that are covered by governmental payers, i.e. Medicare, Medicaid, TriCare, or any other governmental payer, whether that coverage is primary or secondary, are not eligible for the Payment Assurance Discount. The Payment Assurance Discount will be applied by default if all necessary criteria as set forth in this policy are met and the patient does not need to affirmatively elect to participate in the program.
In order to receive the Payment Assurance Discount, the patient must pay their estimated out of pocket expense at the rate of at least $500.00 per covered CT, MRA, or MRI by cash, check, money order, or credit card, on or before the date of service of the covered services.
The patient may also receive a separate Pre-Payment Discount of 10% of the estimated out of pocket expense for services expected to be completed on the same day and not covered by the Payment Assurance Discount. This can be done by pre-paying 90% of the estimated out of pocket expense for those services on or before the date of service.
In the event that any payment is not honored or the patient subsequently opts-out of the program, the Payment Assurance Discount and/or any Pre-Payment Discount shall be reversed and the patient shall be responsible for the original out of pocket expense.
Combination with Other Discounts
The Payment Assurance Discount shall be used in combination with and applied to the balance remaining after application of the 15% Valley Health Employee Discount (if applicable).
The Payment Assurance Discount shall not be used in combination with 10% Pre-Payment Discount; however, in the event that application of the 10% Pre-Payment Discount would be more advantageous to the patient by resulting in a lower out of pocket expense than the Payment Assurance Discount, then the 10% Pre-Payment Discount will be applied in lieu of the Payment Assurance Discount.
Effect of Insurance Bundling Rules
In the event that an originally covered CT, MRA, or MRI is required to be combined with other more complex services due to the billing requirements of the patient’s insurance, then the Payment Assurance Discount cannot be applied as the reimbursement methodology of the combined services will have changed.
In some cases, this combination of services may result from a subsequent admission, surgery, or emergency department visit; and thus, may not have been foreseeable at the time the covered CT, MRA, or MRI was provided. In such cases, any pre-payment will receive a proportional pre-payment discount and the patient billed for any increase in out of pocket or refunded if the pre-payment is more than the final out of pocket expense.
Effect on other Valley Health Discounts and self pay programs
Insurance contractual discounts are not affected by the Payment Assurance Discount as this discount applies only to the patient out of pocket expense after any insurance claims have been processed.
The Valley Health 15% Employee Discount shall be applied after adjudication of all claims by all insurance coverages on the account to the final explanation of benefits (EOB) patient responsibility amount transferred to the Self-Pay liability bucket on all accounts on which the current Valley Health employee insurance coverage is active and adjudicated a claim that resulted in a Patient Responsibility amount for any reason other than lack of patient eligibility or any other denial resulting from a patient’s lack of compliance with the provisions of their insurance contract. Valley Health employees and their dependents who are eligible for the Employee Discount but not covered by the Valley Health insurance plan must manually request the Employee Discount as a mechanism does not currently exist in Epic to reliably identify employees and their covered dependents. In cases in which the patient out of pocket expense after insurance and/or after application of the Employee Discount, if applicable, is less than $500.00 per covered CT, MRA, or MRI, the Payment Assurance Discount shall not be used, regardless of whether the patient paid $500.00 per covered CT, MRA, or MRI. In such cases, the patient will be given credit for the Pre-Payment Discount, calculated as 11.1111% of the pre-paid amount.
The Payment Assurance Discount shall not be used in combination with other Valley Health patient Pre- Payment or Prompt-Payment discounts; however, the patient discount structure that provides the lowest out of pocket expense to the patient for the covered services shall be applied. Thus, if another combination of discounts for which the patient would otherwise be eligible results in a lower patient out of pocket, than that combination of discounts shall be used in place of the Payment Assurance Discount. For the purposes of determining eligibility for the Payment Assurance Discount and Pre-Payment Discount, any monies to be applied to these discounts will first be applied to the covered CT’s and MRI’s and any remaining pre-paid amount shall receive a proportional 10% Pre-Payment Discount credit.
The Payment Assurance Discount has no effect on the Valley Health Financial Assistance Program.
Patient Estimates: Patient out of pocket estimates are based on the best information available at the time the estimate is prepared and the final patient out of pocket liability after services have been performed and all claims have been adjudicated by all eligible insurers may ultimately be greater or less than the original estimate.
In the event that the Payment Assurance Discount is originally believed to be applicable based upon an estimate but the patient out of pocket responsibility after insurance adjudication is ultimately less than $500 per CT, MRI, or MRA, then the Payment Assurance Discount shall not be applied and the patient shall be given credit for a Pre-Payment Discount at 11.1111% of the amount pre-paid, if such discount has not already been taken. Any resulting credit balances will be processed as indicated below under “Discounts resulting in a Credit Balance”. In the event that the patient out of pocket liability is ultimately greater than the estimate, the Payment Assurance Discount will continue to apply, capping the patient liability for covered CT’s, MRA’s, or MRI’s at $500 per covered procedure as indicated by the final insurance explanation of benefits. Any remaining out of pocket liability for non-covered services shall be billed to the patient if the overall account balance is $10.00 or more.
In the event that the original out of pocket estimate materially under-estimated the patient’s out of pocket liability to the degree that the original estimate indicated that the patient would not be eligible for the Payment Assurance Discount because the expected out of pocket would be less than $500 per covered CT, MRI, or MRA and, after final claims adjudications, the ultimate patient out of pocket is greater than $500 per covered CT, MRI, or MRA, then the patient will be given 30 days from the date of the first statement to take advantage of the Payment Assurance Discount; however, in order to be retro-actively eligible: (1) The estimate must be documented, (2) payment of at least $500 per CT, MRA, or MRI must be received within 30 days of the date of the first statement before such discounts will be applied, and (3) the patient must notify Valley Health of their intention to take advantage of the program within the 30 day window. Discounts resulting in a Credit Balance: Small Balance Credits: In the event that application of the Payment Assurance Discount, Pre-Payment Discount, or any other patient discount results in a credit balance between $ -0.01 and $ -9.99, the contributing discount shall be reversed up to the amount of the credit balance in order to create an overall account balance of $0.00, provided the reversal is not greater than the original amount of the discount. Credit Balances in Excess of $ -9.99: In the event that application of the Payment Assurance or Pre- Payment Discount in conjunction with a patient payment results in a credit balance in excess of $ -9.99, then the patient payment and any patient discounts shall each be partially reversed at a pro-rata level to create an overall account balance of $0.00 and the amount of patient payment that is reversed shall be refunded to the patient or applied to any other amounts owed by the patient or guarantor in accordance with the Valley Health refund policy.