Sample sliding fee schedule policy for medical practices (free)

Establish a sliding fee scale for your healthcare practice and make sure you're taking the necessary steps to protect it financially.

Copy this sample application, edit according to your policy, and get started today.

Name of Practice: 

Effective date: 

POLICY: To make available discount services to those in need. 

PURPOSE: This program is designed to provide discounted care to those who have no means, or limited means, to pay for their services (uninsured or underinsured).

[Name of Practice] will offer a Sliding Fee Discount Program to all who are unable to pay for their services. [Name of Practice] will base program eligibility on a person’s ability to pay and will not discriminate on the basis of age, gender, race, sexual orientation, creed, religion, disability, or national origin. The Federal Poverty Guidelines (http://aspe.hhs.gov/poverty) are used in creating and annually updating the sliding fee schedule to determine eligibility. 

PROCEDURE: These guidelines are to be followed in providing the Sliding Fee Discount Program.

1. Notification: [Name of Practice] will notify patients of the Sliding Fee Discount Program by: 

2. Provision of services: All patients seeking outpatient services at [Name of Practice] are assured that they will be served regardless of ability to pay. No one is refused service because of lack of financial means to pay, so long as they complete and are found eligible in the application process.

3. Requests for discount: Requests for discounted services may be made by patients, family members, social services staff, or others who are aware of existing financial hardship.

Discounted services would apply effective the date of application approval going forward.

Information and forms can be obtained from the Front Desk.

4. Administration: The Sliding Fee Discount Program procedure will be administered through the [Title of Staff Member Responsible for Handling Program] or their designee. Information about the Sliding Fee Discount Program policy and procedure will be provided and assistance offered after completion of the application. Dignity and confidentiality will be respected for all who seek and/or are provided charitable services.

5. Alternative payment sources: All alternative payment resources must be exhausted, including all third-party payment from insurance(s), Federal and State programs.

6. Application: The patient/responsible party must complete the Sliding Fee Discount Program application in its entirety. By signing the Sliding Fee Discount Program application, persons authorize [Name of Practice] access in confirming income as disclosed on the application form. Providing false information on a Sliding Fee Discount Program application will result in all Sliding Fee Discount Program discounts being revoked and the full balance of the account(s) restored and payable immediately.

Initial application: If an application is unable to be processed due to the need for additional information, the applicant has two weeks from the date of notification to supply the necessary information without having the date on their application adjusted. If a patient does not provide the requested information within the two-week time period, their application will be re-dated to the date on which they supply the requested information. Any accounts turned over for collection as a result of the patient’s delay in providing information will not be considered for the Sliding Fee Discount Program.

Renewal applications: A patient who receives discounted services under this policy is required to submit an updated application every 12 months or if their financial situation changes. Failure to meet the annual financial information requirement may result in the patient no longer being eligible for the Sliding Fee Discount Program. If a patient is delinquent in meeting the updated annual application requirement, [Name of Practice] will mail the patient a notice they are being terminated from the Sliding Fee Discount Program unless they submit the required financial information within the time frame (10 business days) noted in the letter. If a patient does not submit the renewal information, they are no longer eligible for the discounted services per the date in the notice letter.

7. Discounts: Discounts will be based on income and family size only. [Name of Practice] defines a family as head of household, spouse, and dependent children.

8. Income includes: Earnings, unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, public assistance, veterans' payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources. Noncash benefits (such as food stamps and housing subsidies) do not count.

9. Requirements: Applicants must provide the following: prior year W-2, two most recent bank statements, and two most recent pay stubs. Self-employed individuals will be required to submit detail of the most recent three months of income and expenses for the business. Adequate information must be made available to determine eligibility for the program. Self-declaration of income may only be used in special circumstances. Specific examples include participants who are homeless. Patients who are unable to provide written verification must provide a signed statement of income, and why they are unable to provide independent verification. This statement will be reviewed and final determination as to the sliding fee percentage will be made. Self-declared patients will be responsible for 100% of their charges until management determines the appropriate category. 

10. Updates: The sliding fee schedule will be updated during the first quarter of every calendar year with the latest federal poverty guidelines (http://aspe.hhs.gov/poverty).

11. Notice: The Sliding Fee Discount Program determination will be provided to the applicant(s) in writing, and will include the percentage of Sliding Fee Discount Program write off, or, if applicable, the reason for denial. If the application is approved for less than a 100% discount or denied, the patient and/or responsible party must immediately establish payment arrangements with [Name of Practice]. 

The applicant has the option to reapply after the 12 months have expired or any time there has been a significant change in family income. When the applicant reapplies, the look back period will be the lesser of six months or the expiration of their last Sliding Fee Discount Program application.

12. Refusal to pay: If a patient verbally expresses an unwillingness to pay or vacates the premises without paying for services, the patient will be contacted in writing regarding their payment obligations. If the patient is not on the sliding fee schedule, a copy of the Sliding Fee Discount Program application will be sent with the notice. 

If the patient does not make effort to pay or fails to respond within 60 days, this constitutes refusal to pay. At this point in time, [Name of Practice] can explore options not limited to, but including offering the patient a payment plan, waiving of charges, or referring for patient collections efforts.

13. Storage of information: Information related to Sliding Fee Discount Program decisions will be maintained and preserved in a centralized confidential file located in the [Title of Staff Member Responsible for Handling Program] office, in an effort to preserve the dignity of those receiving free or discounted care.