This policy is intended to determine the appropriateness of discounted care to those who have no means, or limited means, to pay their medical services. In addition to quality healthcare, patients are entitled to financial counseling by someone who can understand and offer possible solutions for those who cannot pay in full. The Patient Account Representative’s role is that of patient advocate, that is, one who works with the patient and/or guarantor to find reasonable payment alternatives.

Heartland Women’s Healthcare (HWHC) will offer a sliding fee discount (SFD) program to all who are unable to pay for their services. HWHC 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 are used in creating and annually updating the SFD to determine eligibility:



Under no circumstances will HWHC engage in any of the following practices with respect to the waiving or lowering of coinsurance and/or deductibles:

  1. Waive or lower co-insurance and deductibles that do not meet the requirements outlined in our Policy.
  2. Charge Medicare beneficiaries or private insurance beneficiary’s different amounts than those charged to other persons for similar services.
  3. Fail to collect co-insurance and deductibles from a specific group of patients for reasons unrelated to indigence or managed care contracting, (to obtain referrals or to induce patients to seek care in my practice vs. another provider’s practice who does not waive co-pays and/or deductibles).
  4. Accept “insurance only” or TWIP (take what insurance pays) as payment in full for services rendered.
  5. Fail to make a reasonable collection effort to collect a patient’s balance.


Financial Hardship Notification:
HWHC will notify patients of the SFD Program by:

  1. Offering notification of the SFD Program to all patients upon check in. Patients interested in the SFD program will be provided the SFD application by the front office staff.
  2. SFD Program options will be defined within collection notices sent out by HWHC.
  3. An explanation of our SFD Program and our application form are available on HWHC’s website as well as available at our practice locations.
  4. HWHC places notification of SFD Program in the clinic waiting area.

Financial Hardship Criteria:
HWHC will make the decision whether to reduce on a sliding scale or waive certain fees by reviewing:

  • The patient/guarantor’s annual income; and
  • The patient/guarantor’s family size

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.

In order to verify income, applicants must provide one of the following:

  1. Prior year W-2,
  2. Two most recent pay stubs,
  3. Letter from employer, or
  4. Form 4506-T (if W-2 not filed).
    • 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.

Family is defined as a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing together; all such people (including related subfamily members) are considered as members of one family.

HWHC reviews all applications in combination with the current year’s federal poverty guidelines to assist in determining qualifications for a financial hardship reduction or waiver. (Attachment A).

Those with incomes at or below 100% of poverty will receive a full 100% discount. Those with incomes above 100% of poverty, but at or below 200% of poverty, will be charged according to the attached sliding fee schedule. The sliding fee schedule will be updated during the first quarter of every calendar year with the latest Federal Poverty Guidelines.

In certain situations, patients may not be able to pay the discounted fee. Waiving of charges may only be used in special circumstances and must be approved by the Directory of RCM, or their appointed designee. Any waiving of charges will be documented in the patient’s medical record along with an explanation.

An application for a financial hardship (Attachment C) for medical expenses must be completed by the patient and/or guarantor in its entirety. The financial hardship application form can be obtained by visiting one of the HWHC practices or online at www.usaobgyn.com . Forms may also be requested from the HWHC Business Operations Office through submission of a written request via email, fax at 618-997-5285, or U.S. Mail at Heartland Women’s Healthcare 1407 McPherson Dr. Mt. Vernon, IL 62864.

Applicants are required to return the completed forms and submit all required documentation to HWHC within 180 days of the date of service.

Required Confidentiality of Information:

HWHC requires independent information to support claims of financial hardship. The information submitted will be treated confidentially and will only be reviewed by HWHC administrative staff involved in processing and reviewing information for reduction or waiver of medical expenses.

Time Frame:

After an application and verification information is received, the HWHC patient account specialist is required to indicate the date they received the application and that the application is under review. The patient account specialist will consider the overall financial situation of the applicant and render a decision based on the guidelines as set forth in this policy.

All decisions will be made within 10 working days from the time that HWHC receives and reviews all required information. All determinations are pursuant to the hardship guidelines and are discretionary and in the sole determination of HWHC.

Applicants will receive written notification outlining whether or not the application has been approved or denied and the reasons why. If an application is denied the patient and/or guarantor is able to reapply if their financial situation significantly changes.

HWHC administrative staff will maintain all documentation related to the financial hardship waiver process as confidential. This documentation will include all supporting documentation including the waiver request and all documents provided in support of the request. Verification of ongoing qualification for financial hardship may be conducted at any time at HWHC’s discretion or at the applicant’s request.



Each department providing patient access, financial counseling or patient accounting services is responsible for following the procedures outlined in this policy.

Education related to this policy and necessary documentation will be provided to all applicable HWHC staff.

Performance improvement procedures will be instituted to support compliance with the provisions of this policy

Financial Hardship- Attachment A


Financial Hardship Application- Attachment C

Please complete the application and attached financial statement. Please return all forms and required documentation in person, by e-mail, by fax 618-997-5285, or by U.S. Mail to Heartland Women’s Healthcare 1407 McPherson Dr. Mt. Vernon, IL 62864.

Financial Hardship Application
Household Size:
Household Income
Amount (Gross wages, salaries, tips, etc)
Frequency (Circle one)
Other Income
Income from business, selfemployment, and dependents
Unemployment compensation, workers compensation, Social Security, Supplemental Security income, public assistance, veterans payments, survivor benefits, pension or retirement income.
Retirement Pension
Child Support, Alimony
Interest Income
Note: To comply with federal regulations, in order to give you a discount on our medical services, it is necessary for us to ask some personal questions.

Your answers will be kept on file and in strict confidence. You must verify your gross annual income at least every year. We will need proof of the household income for each working household member.
The documents needed for review for a financial hardship discount are as follows:
 Prior year W-2,
 Two most recent pay stubs,
 Letter from employer, or
 Form 4506-T )if W-2 not filed)

Your annual income and your family size will be used to calculate your discount

I certify that the family size and income information shown above is correct.

(Typing your name here will be counted as a E-Signature)
By clicking Submit you agree the above information is correct and agree that all signatures are E-Signatures.