These are some misconceptions patient access has about 501(r) requirements for financial screening, which became effective with the Affordable Care Act.

“I see this as a pretty significant area of risk for patient access,” says David Figueredo, business development manager for revenue optimization services at Change Healthcare in Nashville, TN. The regulations have been in place since January 2016, but some departments still are not in compliance. “Hospitals are finding that efforts that they made in 2014 and 2015 aren’t as compliant as they thought they were,” Figueredo adds.

Figueredo says patient access leaders should ask these questions: “Where might the department go wrong? What might an individual patient access employee be doing to cause issues? How do I mitigate that risk? Will technology help? If we are meeting the need, how are we documenting it?”

At many hospitals, financial assistance traditionally has been a “back end” activity handled by patient accounts. Sandra J. Wolfskill, FHFMA, director of healthcare finance policy at the Healthcare Finance Management Association, says, “So patient access staff assume nothing has changed for them. This could not be further from the truth.”

If patients complain they weren’t told by patient access about financial assistance, “that can trigger a whole sequence of audits,” Figueredo says.

Auditors will be interested in whether the patient access department followed its own policies and procedures.

“They will look at whether or not you adhere to what you told the public, and that policies are nondiscriminatory, and uniformly and rigorously applied,” Figueredo says.

Auditors want to see financial screening carried out consistently. “Are you screening all patients for financial aid? Or is it more of an on-demand, hit-or-miss process?” Figueredo asks.

Available to All

An analysis of more than 1,800 nonprofit hospitals nationwide found that just 42% reported that they were notifying patients about their potential eligibility for charity care before attempting to collect unpaid medical bills.1 Another problem is that financial aid screening is too narrowly focused.

“Some hospitals have started to align their charity care policies with the Affordable Care Act’s income limits by reducing charity to people who can purchase subsidized marketplace coverage,” notes Sayeh S. Nikpay, PhD, MPH, the study’s co-author. However, many of these people still face difficulties paying for care because of high out-of-pocket costs. “Many low-income people with incomes above 133% FPL have signed up for marketplace coverage with very high patient cost-sharing requirements,” Nikpay adds.

Jessica Curtis, JD, senior advisor of the Hospital Accountability Project at Boston-based Community Catalyst, says the new rules are “all about making information about financial assistance and billing clear and easily available to all patients.” The hospital’s board ultimately is responsible for compliance. “But in reality, a lot of the work of getting information into the hands of every patient is going to fall on patient access,” Curtis adds.


  1. Nikpay SS, Ayanian JZ. Hospital charity care — Effects of new community-benefit requirements. N Engl J Med 2015;373:1687-1690.


  • Jessica L. Curtis, JD, Director, Hospital Accountability Project, Community Catalyst, Boston. Phone: (617) 275-2859. Email:
  • David Figueredo, Business Development Manager, Revenue Optimization Services, Change Healthcare, Nashville, TN. Phone: (615) 932-3654. Email:
  • Sayeh S. Nikpay, PhD, MPH, Assistant Professor, Department of Health Policy, Vanderbilt University, Nashville, TN. Phone: (615) 875-9280. Email:
  • Sandra J. Wolfskill, FHFMA, Director, Healthcare Finance Policy, Healthcare Finance Management Association, Westchester, IL. Phone: (708) 531-9600. Fax: (708) 531-0032. Email:

Go Outside Hospital Walls

Patient access leaders already educate employees, patients, and clinicians on financial assistance policies. Why not the community?

“I see a great deal of interest in the question of how hospitals engage with their communities to improve health,” says Sara Rosenbaum, JD, Harold and Jane Hirsh Professor at George Washington University’s Milken Institute School of Public Health in Washington, DC.

In a 2015 paper, Rosenbaum notes that 501(r) regulations call for hospitals to “essentially push their policies out — not only into their facilities but also into the communities they serve.”1

“Increasingly, hospitals are regarded as community health actors, with the responsibility not only to identify community-wide health needs, but to take measurable steps to address them,” Rosenbaum says.

Maybe the hospital’s financial assistance policy isn’t doing a very good job of meeting the needs of the community. To ascertain this, Holly Lang, a New York City-based contractor specializing in healthcare financing, public policy analysis, and non-profit hospital strategy, suggests patient access leaders ask local charity clinics and Federally Qualified Health Centers for feedback. Ask them how the hospital’s financial assistance policy is working for their patients.

“Often, their patients are going to be the ones qualifying for financial assistance at your hospital,” Lang explains.

This kind of collaboration also could be valuable to the hospital in another way — by reducing preventable ED visits.

“Telling an uninsured patient to follow up with their cardiologist upon discharge is not a feasible directive,” Lang says. “These patients likely wouldn’t have access to a specialist.”

Discharge planning, conducted in partnership with the community-based clinicians most likely to see the patients, is a more realistic strategy.

“You have to create pathways to care that go beyond the hospital’s walls and are tailored to the patient’s socioeconomic need,” Lang says.


  1. Nikpay SS, Ayanian JZ. Hospital charity care — Effects of new community-benefit requirements. N Engl J Med 2015;373:1687-1690.


  • Holly Lang. Phone: (404) 512-8808. Email:
  • Sara Rosenbaum, JD, Harold and Jane Hirsh Professor, Milken Institute School of Public Health, George Washington University, Washington, DC. Phone: (202) 994-4230. Fax: (202) 994-4040. Email: