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Federal Poverty Level (FPL) Guidelines

October 21, 2013

Another year and another change with most recently updated Federal Poverty Level (FPL) guidelines. It’s not so much that the guidelines have been updated as it happens every year. What is really challenging is implementing the guidelines AND enforcing… wait, maybe creating and THEREAFTER enforcing a policy for verifying patient income and assuring “risk avoidance” for Payer of Last Resort (PLR). You see even if your practice management software has the ability to automatically calculate a patient’s FPL, like all things in information technology (IT)… it is only as good as the data entered. AND, the data entered has only as much integrity as the person who captures it… this does assume s/he has been well trained on the process, right? 

When PMG asks CHCs across the country “How often do you update a patient’s FPL determination?”  The answer is usually “annually” or “once per year.”  But what if you see a patient in December of 2011 and that patient frequents your CHC a dozen or more times during the first half of 2012… well in advance of their one year anniversary of 2011’s FPL determination.  Several thoughts rush to mind: 

1. Is the patient still obtaining a discount for being at 125% of poverty with your CHC?  But what if the increase in the 100% of poverty income ceiling results in your patient now being at 100% of poverty because his/her salary did not change?

2. Is the patient still on Medicaid with no other insurance? You won’t know if you don’t check a pay-stub to see if s/he is having any money removed from his/her paycheck for benefits… in PMG’s mind, this opportunity alone makes pay-stubs the preferred (if not exclusive) option for income verification.

3. If the patient says s/he has no other insurance (or even if they do) are you having EVERY patient sign an affidavit to attest that they have no other insurance… this is “Payer of Last Resort (PLR) Risk Avoidance” in action. 

Many CHCs don’t have a formal, written policy for income verification, never mind PLR. In the end, if (when) you get audited, the policy and demonstration of its effectiveness with patient attestations… these may be your only defense.

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