Patients

Financial Assistance Policy

1.0 Scope:

1.1 Applicable Entities:
This policy applies to Texas Institute for Surgery, LLP (TIS) as an affiliate of Texas Health Resources.

1.2 Applicable Departments:

1.2.1 This policy applies to all hospital departments.

1.2.2 This policy does not apply to bills from doctors, outside labs or other providers. See Attachment C.

2.0 Purpose:

2.1​This Policy establishes the framework pursuant to which TIS identifies patients that may qualify for financial assistance, provides financial assistance, and accounts for financial assistance. This Policy also serves to meet the requirements set forth in state and federal laws, including but not limited to: Texas Health and Safety Code Chapter 311 and Internal Revenue Code Section 501(r).

3.0 Policy:

3.1 All patients will be eligible to apply for financial assistance at any time during the continuum of care or billing cycle. Patients are given the opportunity to apply for financial assistance up to 365 days from the date of service. Each patient’s situation will be evaluated according to relevant circumstances, such as income, assets or other resources available to the patient or patient’s family when determining the ability to pay the outstanding patient account balance. Medically necessary emergency care will not be delayed or withheld based on the patient’s ability to pay. Cosmetic or non-medically necessary procedures are not covered by this policy. The TIS Financial Assistance Policy will be administered under the Eligibility Guidelines consistent with federal and state laws for budgeting, determining, and reporting financial assistance. It is the intent of the TIS Financial Assistance Policy to provide community benefits through financial assistance in accordance with the provisions of Texas Health & Safety Code Section 311.043-045 and Internal Revenue Code Section 501(r).
3.2 Procedures that are deemed not emergency or medically necessary, including but not limited to cosmetic surgery are not covered by this policy.

4.0 Policy Guidance:

4.1 TIS’s Financial Assistance Policy is available for qualifying individuals who are unable to pay their hospital bill. TIS is dedicated to administering its financial assistance policy in a fair, consistent and objective manner respecting the dignity of each patient served. TIS’s Financial Assistance Policy will be administered in a manner that seeks to allocate financial assistance in a way that maximizes the benefit received by the communities TIS serves. No patient will be denied financial assistance because of their race, religion, or national origin or any other basis which is prohibited by law. In implementing this financial assistance policy for the benefit of the communities TIS serves, TIS will comply with all applicable federal, state, and local laws, rules, and regulations.

4.2 Patients with a family income at or below 200 percent of applicable federal poverty guidelines or patients with a family income above 200 percent of applicable federal poverty guidelines who have significant unpaid medical bills may be eligible for financial assistance if the patient lacks sufficient funds to pay the out-of-pocket portion of their hospital bill. Those individuals eligible for financial assistance will not be charged more than Amounts Generally Billed (AGB) to people who have insurance coverage for the same care.

4.3 A patient who is unable to pay his or her hospital bill is encouraged to apply for financial assistance by completing a Financial Assistance Application. Hospital admissions, along with TIS business office personnel, are all familiar with the TIS Financial Assistance Policy and can answer questions relating to the policy. All applications will be reviewed and a determination made as to whether all or a portion of the patient’s hospital bill qualifies for financial assistance. It is the responsibility of the patient to actively participate in the hospital’s financial assistance screening process. This includes providing the hospital with information concerning actual or potentially available health benefits coverage (including Medicaid eligibility and available COBRA coverage.) A patient can be denied financial assistance if they do not provide the information that has been requested in a timely manner. In some cases, TIS may be able to determine from financial and other information provided by independent third party vendors that a patient qualifies for financial assistance even though a financial application has not been completed.

4.3.1 Applying for Assistance

a. Methods for Obtaining a Financial Assistance Application
The patient or responsible party may request a Financial Assistance Application:

• In person (Admission Office)
• By phone at 1.800.890.6034
• By mail at 500 E. Border St. Arlington, TX 76010
• Visiting the Business Office (500 E. Border St., Arlington, Texas 76010)
• By emailing *protected email*

b. Communication Requirements – Any person seeking health care services at TIS should be provided written information about the TIS Financial Assistance Policy as part of the admission process. The hospital will make reasonable efforts to orally notify patients about the financial assistance policy and how to obtain assistance with the application process at various points before, during and after the patient receives services. Written notices shall also be conspicuously posted in both English and Spanish in the hospital’s general waiting area, emergency department and in such other locations as the hospital deems likely to inform patients of the existence of the TIS Financial Assistance Policy. In addition, information describing the TIS Financial Assistance Policy shall be posted on the TIS website. Instructions on how to apply can be found on the reverse side of each THR billing statement. Patients are given 130 days to apply for financial assistance before any type of negative credit report is made by collection vendors.

c. Patient Counseling – Admission, Business Office, Social Services personnel, financial counselors and/or hospital chaplains should encourage patients who are at financial risk as a result of the amount they are expected to owe “out-of-pocket” to complete a TIS Financial Assistance Application. To facilitate the process, it is preferred that financial screening occur and a Financial Assistance Application be completed prior to discharge. In no case, will screening for financial assistance eligibility take place prior to providing medically necessary emergency care in accordance with the requirements of the Emergency Medical Treatment and Active Labor Act.

d. Financial Assistance – Request Initiated by Patient/Responsible Party – A Financial Assistance Application must be provided to any person requesting financial assistance. Financial assistance may only be granted if sufficient information is available to allow for a determination that the patient satisfies the eligibility guidelines outlined in Attachment A of this policy. TIS may utilize information reported on financial applications and information gathered from independent third party sources to evaluate a patient’s eligibility for financial assistance.

e. Requests Initiated on the Patient’s Behalf – A request for financial assistance may be submitted by TIS personnel and/or its agent (on behalf of a patient or responsible party) who have knowledge of the patient’s financial situation. All known facts surrounding the patient’s financial condition shall be documented in a request initiated by TIS personnel.

f. Request Initiated by a Third Party – TIS can determine that a patient qualifies for financial assistance under the policy through review and analysis of financial and other information provided by an independent third party vendor. In these situations, a formal Financial Assistance Application is not required.

g. Follow-Up Collection Efforts – In general, no subsequent attempt shall be made to collect charges from the patient or responsible party which have been approved for 100 percent write-off under the TIS Financial Assistance Policy (subject to the rights of subrogation) except to the extent a patient or responsible party receives a recovery from any third party or other source. An approval of financial adjustment shall not be construed as a waiver by TIS of its ability to enforce a hospital lien for reimbursement of any amount owed by a third party liability carrier on behalf of a patient. Financial discounts may be completely or partially reversed in the event of a recovery from a third-party or other source.

h. The following collection activities will occur during the first 120 days that a medical bill is outstanding to include:

• Summary billing statements will be sent to the patient (Identifying: Total Charges, Insurance Payments, Discounts, Patient Payments and the current balance.)

• Calls will be made to the patient using an outbound dialer system.

• Collection letters will be sent to the patient by agencies under contract with TIS. (Credit reporting will not take place within the first 120 days after the date of discharge)

i. Actions that may be taken to obtain payment after a medical bill has been outstanding for at least 120 days include:

• Transfer of patient account to an outside collection agency. The collection agency will attempt to obtain a response from the patient or responsible party by using letters and phone calls for at least 30 days after receiving the account.

• Placement of a past due comment on patient’s credit report no earlier than 30 days after receiving the account.

4.3.2 Approval and Reporting

a. Management – The TIS Vice President of Finance is responsible for the oversight of the TIS Financial Assistance Policy. The Texas Health Vice President Revenue Cycle Operations is responsible for the day-to-day management of the TIS Financial Assistance Policy.

b. Information Verification -The Texas Health Vice President Revenue Cycle Operations shall establish procedures that specify what application information is subject to verification. In no case, should the establishment of verification procedures discriminate against any group of patients nor unduly limit a patient’s access to financial assistance.

c. Manual Approval – Services Already Rendered – TIS’s business office personnel shall review all available information and determine the appropriate level of financial assistance in accordance with procedures established by the Texas Health Vice President of Revenue Cycle Operations. The final approval for financial write-offs will be the responsibility of the Vice President of Finance. Approval is delegated down to various levels of management, corresponding with the size of the current patient balance due.

d. Approval – Prior to Providing Services – TIS shall implement a review process to determine eligibility for financial assistance. Occasionally, a patient or physician may seek an eligibility determination in advance of hospital services being provided. In those cases the entity President or financial officer must approve the request. In granting financial assistance to individual patients in non-emergent situations, hospital leadership should consider the availability of alternative community resources, continuity of care concerns and the potential financial impact on the hospital’s ability to grant financial assistance broadly to the community it serves. Regardless of whether or not financial assistance has been approved, patients will receive medically necessary emergency care without delay.

e. Notification to Applicants – In general all patients who apply for financial assistance will be notified within a reasonable time regarding the status of their request.

• Approved – The response to the patient will be sent via mail within 30 days of receipt of the completed Financial Assistance Application.

• Denied or Pended/Incomplete – The response to the patient will be sent by mail within 30 days and will include instructions for the patient if they choose to appeal any adverse decision. If the patient’s application was incomplete, THR’s collections activities will be halted for 30 days. If the patient does not supply the needed data, collections will resume in 30 days and the balance could end up with a collection agency and a “past due” comment may be put on the patient’s credit report.

• Presumptive/Automated Screening – Notification is not sent to patients who were granted approval based on an automated (presumptive) financial assistance process.

f. Appeals – An appeal of a denied Financial Assistance Application will be considered if material changes in a patient’s circumstances are documented. Changes may include, but are not limited to, a change in employment, health, marital, or family status. Appeals can be made by the patient anytime during the first 365 days from the initial billing date.

g. Reporting – All financial adjustments must be recorded on the books and records of TIS on a monthly basis and a financial assistance log shall be maintained. At a minimum, the financial assistance logs must contain the following information: patient’s name, gross hospital charges, amount of payments received on the patient’s account, the amount of financial adjustment, and the financial assistance classification (e.g. Financially Indigent, Medically Indigent or Catastrophically Indigent).
h. Record Retention – Documentation sufficient to identify each patient’s income, the amount owed by the patient, the review and approval processes that were followed, and the patient’s status as Financially Indigent, Medically Indigent, or Catastrophically Indigent shall be maintained by the TIS business office for the period required by the TIS record retention policy.

i. Remaining Balances – Patients who are approved for financial assistance will never be billed for a remaining amount that is greater than the TIS AGB (amounts generally billed) as defined in section 5.0.

5.0 Definitions:

5.1 Amounts Generally Billed (AGB) – An average of the amounts generally billed to insured individuals. Claims during the prior fiscal year (12 months) are included in the calculation. The claims include Medicare fee-for-service as well as all other private health insurers. Each of the hospitals adopting this policy separately calculates an AGB percentage annually and uses the “Look Back Method”, as defined by Internal Revenue Code Section 501(r). TIS compares the amount paid by insured patients and their insurance companies in the prior fiscal year. A patient approved for financial assistance cannot be charge more than AGB. THR will apply one system-wide rate for all hospitals adopting this financial assistance policy. The AGB is calculated annually and the Texas Health Senior Vice President Finance will determine the system-wide AGB rate, which cannot be more than lowest individual hospital AGB. A copy of the calculation is available in Attachment D.

5.2 Annual Income – If the patient is an adult, the term Annual Income refers to the total gross annual income of the patient and any other responsible party. If a patient is married, Annual Income will also include the total gross annual income of the patient’s spouse. If the patient is a minor, the term Annual Income refers to total gross annual income of the patient, parents, and/or any other responsible party.

5.3 Current Patient Balance Due – The amount owed by a patient after the application of appropriate third party payments and discounts. For patients without insurance, this amount represents the balance after an uninsured discount has been applied.

5.4 Eligibility Criteria – The financial criteria and procedures established by this financial assistance policy are described in Attachment A. The financial criteria shall include income levels indexed to the federal poverty guidelines and means testing. The financial criteria does not set the income level for financial assistance lower than that required by Texas counties under Section 61.023 of the Indigent Health Care & Treatment Act or higher; in the case of the Financially Indigent, than 200 percent of the federal poverty guidelines. The federal poverty guidelines are published in the Federal Register in February of each year and, for purposes of this financial assistance policy, will become effective the first day of the month following the month of publication. The guidelines published by the Texas Department of Health Services are found on their website.

5.5 Extraordinary Collection Actions (ECA) – Per IRC Section 501(r), certain actions taken by a hospital against an individual related to obtaining payment for a hospital bill are considered to be extraordinary collection actions. The only ECA which will be carried out under this policy will be the reporting of adverse information to a consumer credit agency or credit bureau either by a TIS or one of its agents. This type of reporting will occur no sooner than 130 days from the date of the first post-discharge bill.

5.6 Financial Assistance Application – A written request from the patient, responsible party or other interested party for financial assistance under the TIS Financial Assistance Policy, which summarizes financial and other information needed to determine eligibility. The content of the Financial Assistance Application will be determined by the Texas Health Vice President Revenue Cycle Operations or his/her designee.(see attachment D for a copy of the TIS Financial Assistance Application)

5.7 Financially Indigent – An uninsured or underinsured patient whose Annual Income is less than or equal to 200% of the applicable federal poverty guidelines.
Each patient’s situation will be evaluated according to current relevant circumstances, such as income, assets or other financial resources available to the patient or patient’s family.

5.8 Medically Indigent – A person who’s Current Patient Balance Due exceeds a specified percentage of the patient’s Annual Income, determined in accordance with the Eligibility Guidelines detailed in Attachment A of this policy.

5.9 Medically Necessary Care – In general, non-elective inpatient and outpatient acute hospital services that are reimbursable under the Medicare and/or Medicaid programs.

5.10 TIS Financial Assistance Policy – The policy implemented by TIS to provide financial assistance to patients who qualify as Financially Indigent, Medically Indigent, or Catastrophically Indigent. The Eligibility Guidelines for financial assistance are detailed in Attachment A of this policy.

6.0 Responsible Parties:

6.1 TIS Vice President Finance
6.1.1 Responsible for oversight of the TIS Financial Assistance Policy.

6.2 Texas Health Vice President Revenue Cycle Operations
6.2.1 Responsible for day-to-day management of the TIS Financial Policy.

6.3 TIS Business Office Personnel
5.2.1 Responsible for informing all patients of the existence of the TIS Financial Assistance Policy.

5.2.2 Responsible for review of Financial Assistance Applications and determination of level of financial assistance.

6.3.3​Responsible for notification to applicants of status of their request for financial assistance and their right to appeal an adverse decision.

5.2.4 Responsible for the processing appeals of denied Financial Assistance Applications.

5.2.5 Responsible for the retention of documentation relating to the determination of financial eligibility.

5.3 Texas Health’s Hospitals – All
5.3.1 Responsible for informing patients of the existence of the Texas Health Financial Assistance Policy.

5.3.2 Responsible for implementing a review process to determine financial assistance eligibility for patients in advance of hospital services and notifying patients of the eligibility determination that is made.

5.4 Hospital Finance Officers
5.4.1 If finance assistance is requested prior to a scheduled service, such eligibility determination will need to be approved by the hospital finance officer or their designee.

5.4.2 Responsible for internal controls and processes to appropriately record financial adjustments in the hospital books on a monthly basis.

6.0 External Reference:

6.1 EMTALA – Emergency Medical Treatment and Active Labor Act

6.2 Federal Register Poverty Guidelines

6.3 Indigent Health Care & Treatment Act Section 61.023 (income levels)

6.4 Internal Revenue Service Code Section 501(r)

6.5 Texas Department of Health Services Guidelines

6.6 Texas Health and Safety Code Section 311.043-045

7.0 Related Documentation and/or Attachments:

8.1​Attachment A – Eligibility Criteria

8.2​Attachment B – Financially Indigent, Medically Indigent, Catastrophically Indigent Tables

7.1 Attachment C – List of Covered Entities & Non-Covered Providers/Services

7.2 Attachment D – Amounts Generally Billed (AGB) Calculation

7.3 Co-Payments and Co-Insurance Providing Discounted Pricing to Uninsured

7.4 Final Policy for Collection of Advanced Deposits

7.5 THR Approval, Authorization and Responsibility Matrix

9.0​Required Statements:

Not Applicable
​Attachment A
ELIGIBILITY CRITERIA

The criteria noted in this attachment shall be applied to determine whether a patient is eligible for free or discounted care under the TIS Financial Assistance Policy. Only adjustments relating to those patients meeting the criteria set forth in this Attachment A shall be reported as charity care in a hospital’s statement of operations.

A-1.0 Financially Indigent
A patient/guarantor with estimated Annual Income between 0% and 200% of the federal poverty guidelines shall be approved for financial assistance provided the patient has insufficient funds and financial assets to pay his or her Current Patient Balance Due without incurring an undue financial hardship. In general, a Financially Indigent patient will be eligible for a discount from total gross billed charges in an amount equal to the Current Patient Balance Due at the time of the eligibility determination, of his or her hospital bill less the amount (if any) they are deemed able to pay. Eligibility determination will be based on Annual Income, family size and financial resources. In no case, will the patient’s prior payments plus the remaining Current Patient Balance Due after all discounts are applied be more than the TIS AGB percentage of gross charges.

A-2.0 Automated/Presumptive Financial Approval
In certain situations, TIS may determine that a patient qualifies for financial assistance under this policy through review and analysis of financial and other information provided by an independent third party vendor such as estimated Annual Income, family size and employment status. In these situations, a formal Financial Assistance Application is not required. The TIS review and analysis of available data will be complete within 30 days after the patient liability was established. If TIS cannot determine that a patient qualifies for financial assistance through this review process and a TIS Financial Assistance Application has not been submitted, collection activities will commence in accordance with normal TIS collection procedures. Any ECA will not begin prior to 130 days after the patient liability was established.

A-3.0 Medically Indigent
A Medically Indigent patient is one whose annual income falls between 201% – 500% of the Federal Poverty Income Level and unpaid TIS hospital bills (after payment by all third parties) exceeds 5% of their Annual Income and who are unable to pay the outstanding Current Patient Balance Due. These Medically Indigent patients are eligible for a discount as set forth in Attachment B. However, in no case will the patient’s prior payments plus the remaining Current Patient Balance Due after all discounts are applied be more than the TIS AGB percentage of gross charges. See Attachment B for the complete table.

A-4.0 Catastrophic Medically Indigent: A patient whose outstanding Current Patient Balance Due after payments by all third parties, exceeds 20% of the patient’s total reported Annual Income and the patient is unable to pay the Current Patient Balance Due. These Catastrophic Medically Indigent patients are eligible for a discount ranging from 75% – 95%. However, in no case will a Current Patient Balance Due, after the discount is applied, exceed the TIS AGB percentage of gross charges.

A-5.0 Presumptive Medically Indigent (Gross Billed Charges Exceeding $75,000)

In the case of a patient whose TIS hospital bill reflects charges exceeding $75,000, the account may be eligible for presumptive financial assistance without a completed Financial Assistance Application provided there is sufficient information to determine whether or not the patient otherwise qualifies. The information could include financial data obtained from a third party. In this situation, the minimum patient responsibility shall be 15% of the patient’s responsible portion. However, in no case will the patient’s payments exceed the TIS AGB percentage of gross charges.

A-6.0 Financial Assistance

All patients seeking assistance under the TIS Financial Assistance Policy are encouraged to complete a Financial Assistance Application. A patient whose hospital bill reflects gross charges of $75,000 or less may not be classified as Medically Indigent unless a completed Financial Assistance Application is received by TIS along with materials requested by TIS to verify the income, assets and medical expense amounts reported therein.

A-7.0 Determination of Financial Condition

The determination that a patient has insufficient funds, for both financial and medical indigence, shall be made at the time a patient’s account is reviewed and will be based upon the patient’s existing employment, financial situation, and family status. For purposes of this policy, assets shall include cash, stocks, bonds and other financial assets that can be readily converted to cash. In general, non-liquid assets and the patient/guarantor’s speculative ability to generate future income will not be considered in determining whether or not sufficient funds exist to pay current medical bills.

A-8.0 Reapplication
If additional services are received within 90 days of approval of a Financial Assistance Application, and additional financial assistance is requested, a patient does not need to complete another Financial Assistance Application unless the facts and circumstances suggest that there may have been a material change in the applicant’s financial condition and/or ability to pay.

A-9.0 Non-Emergent Financial Assistance

Financial assistance under the TIS Financial Assistance Policy may be provided to patients with either emergent or non-emergent conditions. Priority under the TIS Financial Assistance Policy is given to patients with emergent medical conditions. In reviewing applications for financial assistance for non-emergent care, TIS will consider the availability of other resources in the community that meet the applicant’s needs, the ability of TIS hospitals to provide the proper continuum of care, and the impact of the specific request on the ability of TIS to provide care to the broad community it serves.

A-10.0 Patient Cooperation

It is the responsibility of the patient to actively participate in the hospital’s financial assistance screening process, to authorize (if required) TIS to access available third party information and to provide requested information on a timely basis, including, without limitations, providing the hospital with information concerning actual or potentially available health benefits coverage (including available COBRA coverage), financial status (i.e. income, financial assets) and any other information that is necessary for TIS to make a determination regarding the patient’s financial and insured eligibility. A patient’s failure to cooperate may result in a denial of financial assistance.

Financial assistance is one option for resolving settlement of a Current Patient Balance Due. If funds are collected on the patient’s account prior to financial assistance approval, they will not be refunded to the patient unless payments exceed the TIS AGB percentage.
​ Attachment B
Financially, Medically, Catastrophic Indigent

Based on Federal Poverty Guidelines Issued 1/22/15

Financially Indigent Classification

Medically Indigent Classification
Balance due must be equal to or greater than the specified % of the patient’s Yearly Income for eligibility
Number in
Household
200%

Specified %
> 5%
> 5%
> 5%
> 10%
> 10%

Number in
Household
201 – 250%
251 – 300%
301 – 350%
351 – 400%
401 – 500%
1
$23,540

1
$23,541-$29,425
$29,426-$35,310
$35,311-$41,195
$41,196-47,080
$47,081-$58,350
2
$31,960

2
$31,861-$39,825
$39,826-$47,790
$47,791-$55,755
$55,756-$63,720
$63,721-$79,650
3
$40,180

3
$40,181-$50,225
$50,226-$60,250
$60-271-$70,315
$70,316-$80,360
$80-361-$100,450
4
$48,500

4
$48,501-$60,625
$60,626-$72,750
$72,751-$84,875
$84,876-$97,000
$97,001-$121,250
5
$56,820

5
$56,821-$71,025
$71,026-$85,230
$85,231-$99,435
$99,436-$113,640
$113,641-$142,050
6
$65,140

6
$65,141-$81,425
$81,426-$97,710
$97,711-$113,995
$113,966-$130,280
$130,281-$162,850
7
$73,460

7
$73,461-$91,825
$91,826-$110,190
$110,191-$128,555
$128,556-$146,920
$146,921-$183,650
8
$81,780

8
$81,781-$102,225
$102,226-$122,670
$122,671-$143,115
$143,116-$163,560
$163,561-$204,450
Discount
100% of
Balance Due

Discount
95% of
Balance Due
90% of
Balance Due
85% of
Balance Due
80% of
Balance Due
75% of
Balance Due

Catastrophic Medically Indigent
If Patient’s Yearly Income exceeds 500% of Federal Poverty Guidelines
Balance Due
Discount
Balance due is equal to or greater than 100% of patient’s Yearly Income
95% of Balance Due
Balance due is greater than 80% and less than 100% of patient’s Yearly Income
90% of Balance Due
Balance due is greater than 60% and less than 80% of patient’s Yearly Income
85% of Balance Due
Balance due is greater than 40% and less than 60% of patient’s Yearly Income
80% of Balance Due
Balance due is greater than 20% and less than 40% of patient’s Yearly Income
75% of Balance Due

​Attachment C
FINANCIAL ASSISTANCE POLICY
LIST OF COVERED TEXAS HEALTH RESOURCE’S ENTITIES

Texas Health Wholly Controlled Hospitals

Texas Health Arlington Memorial Hospital
Texas Health Harris Methodist Hospital Azle
Texas Health Harris Methodist Hospital Cleburne
Texas Health Harris Methodist Hospital Fort Worth
Texas Health Harris Methodist Hospital Hurst-Euless Bedford
Texas Health Harris Methodist Hospital Southwest Fort Worth
Texas Health Harris Methodist Hospital Stephenville
Texas Health Harris Specialty Hospital Fort Worth
Texas Health Presbyterian Hospital Allen
Texas Health Presbyterian Hospital Alliance
Texas Health Presbyterian Hospital Dallas
Texas Health Presbyterian Hospital Denton
Texas Health Presbyterian Hospital Kaufman
Texas Health Presbyterian Hospital Plano

Texas Health Joint Venture Affiliates

Physicians Medical Center, LLC (dba Texas Health Center for Diagnostics & Surgery Plano)
Southlake Specialty Hospital, LLC (dba Texas Heath Harris Methodist Hospital Southlake)
Texas Institute for Surgery LLP, (dba Texas Institute for Surgery at Texas Health Presbyterian Dallas)
Rockwall Regional Hospital, LLC (dba Texas Health Presbyterian Hospital Rockwall)
Flower Mound Hospital Partners, LLC (dba Texas Health Presbyterian Hospital Flower Mound
USMD Hospital at Arlington, LP
USMD Hospital at Fort Worth, LP
AMH Cath Labs, LLC (dba Texas Health Heart & Vascular Hospital Arlington)

If the services were not included in the hospital bill from TIS, those services are not covered by the TIS Financial Assistance Policy.

NON-COVERED PROVIDERS/SERVICES

Certain professional and physician services are often performed along with hospital services as ordered by various treating physicians. A patient may be billed separately for services provided by their attending physician, ER physician, radiologists, hospitalists, pathologists, cardiologists, neonatologists, anesthesiologists and/or other non-hospital providers.

The TIS Financial Assistance Policy applies only to services provided by TIS. Patients may receive additional bills for health care services from other providers which are not covered under this policy. The number of non-covered providers delivering emergency or Medically Necessary Care is extensive and frequently changing. Therefore, the following types of providers and/or lines of service have been identified as those services which are not covered under this financial assistance policy. A more extensive listing of the non-covered providers by entity can be obtained free of charge either electronically or on paper by calling 1-682-236-7959.

Non-Covered Providers include the following categories:

Ambulance Charges
Ambulatory Surgery Centers
Anesthesiologist
Attending Physician
Cardiologist
Dialysis Centers
Durable Medical Equipment (DME)
Emergency Room Physician
Home Health
Hospitalists
Neonatologist
Other Professional Providers
Outside Laboratory
Pathologist
Physicians
Radiologist

​Attachment D

AGB CALCULATION