ࡱ> NPMS7 lbjbjUU %7|7|hl        8< |)26(^"((((((($* ,f!) !)P  6)PPP"  (P(PPN'h  (* {  " ((L)0|)(4-4-(P       EMBED MSPhotoEd.3   HYPERLINK "http://www.nonprofithealthcare.org" www.nonprofithealthcare.org PO Box 41015 Washington, DC 20018 877-299-6497 SPECIAL BRIEFING Ohio Attorney Generals Proposed Rules for Charitable Hospitals, Nursing Homes and Other Health Care Organizations July 2006 In late June 2006 Jim Petro, Ohio Attorney General (AG), issued proposed rules, with a thirty-day public comment period (since extended to August 21), that would significantly modify current reporting and other requirements for a variety of charitable organizations, but with some special provisions for charitable hospitals, nursing homes and other health care organizations (e.g., nonprofit health plans covered under the states Charitable Trust Act). The Grantmakers Forum of Ohio is seeking to take the lead on behalf of charitable health care and other organizations in the state in developing comments on these proposed rules. These rules, if adopted, could represent the most detailed, far-reaching regulation by any state of charitable health care and other organizations policies and practices with respect to conflicts of interest, executive compensation and expense reimbursement, and patient billing and collections. While technically the AG is not seeking to require charitable health care and other organizations to adopt and abide by his annual report request and suggested policies, there are very strong incentives for them to do so; i.e., avoidance of increased reporting burdens and potential investigations. This proposed approach, entailing detailed process standards, can be viewed as the opposite end of the spectrum of regulation from that proposed recently by the Illinois Attorney General, which would entail an outcome standard--a quantitative test related to charity care. In addition, these proposed rules would require annual community benefit reporting by not only charitable health care organizations but also other large charitable organizations. Because of the potential precedent-setting nature of this initiative, the Alliance has prepared this special briefing summarizing the key features of the Ohio AGs proposed rules. Stated Goal To improve public and donor confidence in charitable organizations Annual Reports All charitable organizations are encouraged to file a new Annual Report designed by the AG rather than to provide a copy of their federal Form 990 filing (There are separate recommended reports for charitable trusts, charitable organizations under $100,000 gross revenues, charitable organizations over $100,00 gross revenues, charitable hospitals or nursing homes, and other types of charitable health care organizations) If they do not file the AGs new Annual Report voluntarily, the AG would have to launch an investigation to obtain the information requested on the new form In addition to financial information, the AGs Annual Report form for all charitable organizations asks for certain information related to Conflicts of Interest and Executive Compensation/Expense Reimbursement/Insider Loans. Charitable hospitals and nursing homes are also asked questions related to Fair Billing and Collection Practices, and all charitable organizations with gross revenues greater than $1 million would be required to file a Community Benefit Report (full text and summary reports) annually using standardized criteria. Each of these specific areas is discussed below At the end of the Annual Report, the charitable organizations CEO and Treasurer/CFO are each requested to attest to a series of statements with notarized signatures. Conflicts of Interest The AG proposes a specific Conflict of Interest Policy for adoption by all charitable organizations The Annual Report noted above asks if the organization has adopted and abided by a policy that substantially conforms to the AGs suggested Policy If the organization answers no, it is to explain each activity and conflict of interest engaged in that would have or may have violated the AGs suggested Policy, had it been adopted, and explain why such activity was not or may not have been a breach of fiduciary duty. Key provisions of the AGs suggested Policy are as follows: Persons covered include any director, trustee, officer, employee or agent A significant relationship is considered to exist with another party if: The other party is family member including a spouse, parent, sibling, child, stepchild, grandparent, grandchild, great-grandchild, in-law, domestic partner or intimate partner The other party is an entity in which the covered person has a material financial interest (at a minimum more than 10% ownership) The covered person is a director, trustee, officer, employee or agent of the other party The covered person has a compensation arrangement with the other party Transactions and arrangements covered include any in which there is an actual or perceived conflict of interest, including competing interests Covered persons will promptly disclose the existence and circumstances of actual or perceived conflicts of interest in writing to the board of directors as a whole or a board committee delegated powers to consider such transactions, and must refrain from using personal influence to bring about the transaction, and must physically excuse himself from any discussions or votes except to answer questions The organization will, if appropriate, appoint a disinterested person or committee to investigate any reasonable alternatives to the transaction that would not give rise to an actual or perceived conflict of interest The organizations policy may require that a majority of the Board approve the transaction, but if it does, the policy must state that those who voted for it may be jointly or severally liable for damages incurred by the organization if the transaction is not fair and they knew or should have known of improprieties The organization will disclose any belief it has to the covered person that he or she has failed to disclose actual or possible conflicts of interest and provide an opportunity to that person to explain the alleged failure to disclose. If the organization deems the explanation inadequate, it must take disciplinary and corrective action Records will be kept on all proceedings related to the above No covered person who receives compensation can vote on or approve his or her own compensation or compensation of a class of persons that includes the covered person or the compensation of another party with which the covered person has a significant relationship Each director, trustee or officer will annually sign and submit a statement affirming that he or she: has received, read and understands the policy; has agreed to comply with it; and understands that the organization must engage primarily in activities that accomplish its charitable purposes. Employees and agents will annually receive a copy of the policy and be reminded that they are governed by its provisions Periodic reviews will be conducted, to include reasonableness of compensation and benefit arrangements, partnerships, joint ventures and any arrangements with management organizations as well as proper recording of arrangements and conflict of interest proceedings. The policy must state that outside advisors may be used in conducting such reviews, but that where this occurs it does not relieve the board of its responsibility in this regard No covered person receiving compensation can vote on or approve the appointment, compensation and oversight of the accounting firm providing audit services The accounting firm providing audit services cannot provide contemporaneously other non-audit services to the organization, and its lead audit partner or reviewing audit partner cannot have performed audit services for the organization for the past five years. The CEO and CFO of the organization cannot have been employed by the accounting firm providing audit services within the twelve months preceding the initiation of the audit No more than one-third of the boards directors can be involved in covered transactions at any given time The board will receive at least bi-annually a report that summarizes all board activities and minutes where board members have refrained from participating in activities due to a conflict of interest; discloses all contracts approved despite a conflict of interest as well as the percentage of such bids accepted compared to the percentage of other successful bids; and summarizes any instances of failure to comply with the financial reporting and audit provisions of this policy Executive Compensation and Expense Reimbursement The AG proposes a specific Executive Compensation and Expense Reimbursement Policy for adoption by all charitable organizations The Annual Report noted above asks if the organization has adopted and abided by a policy that substantially conforms to the AGs suggested Policy If the organization answers no, it must provide an explanation, identifying each person whose compensation would have or may have violated the AGs suggested Policy by more than $200 If the organization answers on the Annual Report that it compensates board members (other than reimbursement of expenses), compensates in aggregate any person more than $321,360 ((thirty times the minimum wage) or more than 10% of the organizations annual gross revenues, and/or reimburses any person for expenses that would have or may have violated the terms of the AGs suggested Policy, the organization must explain, identifying the name and title of the person, the average hours per week worked and any contributions made to employee benefit plans, deferred compensation, expenses account payments, or any other allowances or fringe benefits If the organization answers in the Annual Report that any expense reimbursement exceeds the Federal Travel Regulations Rates for employee travel, the organization must explain, identifying the number of times this occurred and the total dollar amount in excess If the organization answers in the Annual Report that there were any outstanding loans between the organization or a related third party and an executive or board member, the organization must provide an explanation, listing the number of such loans and the terms, including total dollar amount, repayment terms and security received In all of the forgoing instances, the organization must explain why it believes that any such compensation, reimbursement or loan does not or may not violate the charitable purposes of the organization Key provisions of the AGs suggested Policy are as follows: Persons covered include any director, trustee, officer, employee or agent with respect any entity in a health care system or other multiple organization of which the charitable organization is a part or any related third party. Related third parties include people and firms: supplying goods and services; leasing property or equipment; involved in giving, purchasing, or selling real estate, securities or other property; making donations; and affecting the operations of the organization Covered compensation includes direct salaries, wages, or amounts payable under a separate contract by the charitable organization, any other entity in a health care system or other multiple organization of which the charitable organization is a part, or a related third party Reasonable compensation will be defined as an amount that would ordinarily be paid for like services by like enterprises under like circumstances As a rule, payment of compensation to directors of the board, other than reimbursement of expenses, will be deemed not to be in furtherance of the charitable purposes of the organization. In cases where it is deemed necessary due to the complexity of the responsibility, time commitment, needed skills, or other factors, the organization will first review information on compensation provided by similar organizations (size, programs, geographic scope, board responsibilities). No such compensation will be provided by a related third party, except for reasonable compensation paid for services rendered to that third party for matters unrelated to governance of the charitable organization As a rule, compensation exceeding thirty times the current federal minimum wage ($321,360) or ten percent of the organizations annual gross revenues will be deemed to be not in furtherance of the charitable purposes of the organization. Where it exceeds this threshold the board will have procedural safeguards to ensure that the compensation is not excessive, to include: Approval by a supermajority of the full board, with full knowledge by all members the total compensation by the charitable organization and any other related third parties and with tangible evidence provided to the full board of the reasonableness of the compensation Tangible evidence may include: compensation paid by similarly situated organizations for functionally comparable positions; the availability of similar services in the geographic area; current compensation surveys compiled by independent experts; and actual written offers from similarly situated organizations for the services of the covered person As a rule, the issuance of loans to covered persons by the organization or related third parties will be deemed not to be in furtherance of the charitable purposes of the organization. Where such loans are deemed to be necessary to further those purposes or to not interfere with those purposes, procedural safeguards must be in place, to include at a minimum approval by a majority of the full board, with their full knowledge of the total number and amount of the loans to the covered person by the organization and any related third parties As a rule, reimbursement of expenses at rates greater than those of established by the Federal Travel Regulations for federal employees will be deemed not to be in furtherance of the charitable purposes of the organization. Receipts must be provided for all expenses exceeding $25.00 The board will receive at least bi-annually a report on: all director compensation; all covered compensation to any covered person exceeding thirty times the federal minimum wage or ten percent of annual gross revenues; and all loans made to covered persons by the organization or related third parties including amount, history of repayment and description of any defaults or write-offs Fair Billing and Collection Practices The AG proposes a specific Fair Billing and Collection Practices Policy for adoption by all charitable hospitals and nursing homes The Annual Report noted above asks if the organization has adopted and abided by a policy that substantially conforms to the AGs suggested Policy If the organization answers no, it must provide an explanation, identifying each activity or practice engaged in by the organization that would have or may have violated the AGs suggested Policy, had it been adopted, as well as an explanation, if any, of why that activity or practice does not or may not violate the organizations charitable purposes Key provisions of the AGs suggested Policy are as follows: General principles will include: fair and reasonable charges to uninsured, underinsured, and indigent patients; zero tolerance for abusive, harassing, oppressive, false, deceptive or misleading conduct by employees, attorneys or agents involved in collections; and charitable and humane practices in connection with all debt collection practices The Policy will be communicated in a clear and concise and manner, and multi-lingually where needed, to patients and the community through signage, bills, and brochures Staff involved in billing, collections, admissions, and patient treatment will receive training on these policies, including how patients may obtain more information and submit applications for financial assistance No patient whose annual household income is less than $125,000 for any uncovered treatment will be charged at a rate greater than that paid by the organizations most favored (providing the most revenue in the previous calendar year) nongovernmental insurer. This threshold will be adjusted annually for inflation Patients receiving financial assistance will be billed using the same charge description master prices for non-covered services that it utilizes for treatment provided to a policyholder of its most favored insurer The total charge to such patients will be no more than it would have been paid in aggregate from its most favored insurer and its policy holder under applicable cost-sharing provisions Such patients will receive the same percentage discount as applies to a policyholder of the most favored insurer Measures to estimate patients income levels and ability to pay, and to ensure collection will be simple, dignified and not interfere with or discourage patients access to care. When uninsured patient income information is not obtainable before or at the time service is rendered, the organization will contact the patient at least twice in writing, if necessary, to obtain the information, giving the patient at least 30 days to respond to each request If the organization mistakenly sends a bill to a patient for more than the Policy allows, the patient will be notified promptly of the revised bill Patients indicating lack of insurance or inability to pay will be assisted in obtaining discounted or free care or government-sponsored care, with standardized payment plan options that are reasonable taking into account income and necessary living expenses, after deducting from income expenses for necessary medical costs or existing medical debt payments. Once offered, payment plans will not be withdrawn even if other collection measures have been instituted Restrictions against full charges-billing will apply only to medically necessary services Claims will be submitted in a timely and accurate manner to third party payers, with the patient not liable for the organizations failure to do so if the patient provided its insurance information in a timely manner No bill will be referred to a collection agency or attorney for collection while a claim is pending with a third party payer with whom the organization contracts. Such referrals can be made where the claim was denied through no error by the organization The organization will have a steam-lined billing dispute process on all bills and collection notices, providing an address and toll-free phone number, with phone calls to be returned within one business day and correspondence responded to within ten days If the patient claims that all or part of the bill is not owed, that a third party should pay or that billing documentation is needed, the organization, its collection agency or attorney will cease collection efforts until the patient is provided with supporting documentation on the validity of the bill, which will be provided within ten days with collections suspended for thirty days Records will be kept of all complaints received by the billing offices and where received The board will receive at least bi-annually a report on: the current Policy; the name, income level, and medical debt amount of each patient currently being sued; the number of collection cases involving bankrupt debtors, including those where the organizations claim represents more than 40% of the their outstanding debt; and a summary of all patient billing complaints by category and the number resolved The organization will not refer a patients account to a third party debt collection agency unless: There is a reasonable basis to believe the debt is owed All known third-party payers have been properly billed and the patient is not being billed for any amount that is the third-part payers obligation A reasonable payment plan has been offered for debtors able to provide a reasonable verification of their inability to make in a lump-sum payment, and the patient has not complied with that plan The patient has been provided a reasonable opportunity to apply for free or discounted care if the facts suggest that he or she would be eligible, the application has been processed and the patient notified of the decision The organization will not refuse to supply information of talk to patients whose accounts have been referred to a collection agency or attorney If the organization chooses to use a collection agency or attorney, there will be a written contract, with no payments of performance bonuses, contingency bonus, or other similar payment that is calculated on debt amounts for two or more patients; however, a percentage may be paid on the debt collected from an individual patient. The agency or attorney will be required to: keep a log of oral and written complaints, with the organization receiving a copy six times a year; maintain a record of all communications with patients; provide the appropriate contact information for the organization if requested by the patient; receive training by the organization about its free and discounted care and the means by which the patient may apply; and refer patients who may be eligible for such care to the organization. All collection notices will include language indicating that any concerns may be addressed to the AG Neither the organization, its collection agency nor its attorney will report any patient to a credit-reporting agency as a result of the patients failure to pay a medical bill. Their contacts with patients will be courteous and reasonable in frequency and times of day, and patient requests to limit or cease contacts on bill collections will be honored The organizations general counsel will oversee any debt collection litigation, which will abide by the following: filings no later than seven days after patient is served; all pleadings signed and dated; address of mailed pleading or name of person to whom pleading was delivered; the county listed in the case caption where the lawsuit is or will be venued; and no action that would cause the patient to be arrested as a result of his failure to appear in court, complete paperwork, or respond to any request or action by the organization to collect the debt. A default judgment will not be obtained against a patient without the specific case-by-case approval of the general counsel, which will be based on a reasonable evaluation of whether the patient has or has not adequately answered the complaint, is able or unable to answer it, and has or hasnt received service The organization will have a sample lawsuit information sheet to give patient debtors that contains specific information set forth by the AG in this proposed rule The organization or its agent will not contact a patient if it knows that he is represented by an attorney for debt collection purposes The organization will not give blanket authorization to a debt collection agency or attorney to garnish the patients wages or bank accounts, and the agency or attorney will not proceed with garnishment until the organizations designated individual with authority so approves, after verifying that: the patients wages or funds are unlikely to be exempt from garnishment; the patient is reasonably believed to owe the debt; all known third party payers have been properly billed and amounts owed by the patient are not obligations of any third party payers; a reasonable payment plan was offered where the patient indicated and demonstrated an inability to pay; and the patient was given a reasonable opportunity to apply for free or discounted care where warranted. Also, the organization will not proceed until it has first obtained a court judgment for the amount of the debt The organization will provide a garnishment information sheet to the patient that: contains language specified by the AG in this rule; summarizes any potential bases for exemption from garnishment that may be available to the patient and any time limits that may apply; and provides the garnishment percentages and wage amount The organization will have its general counsel review any request by a patient for an exemption from garnishment The AG may waive any requirements when the organization can demonstrated that compliance would impose a substantial hardship or unjustifiable burden Annual Community Benefit Report In addition to describing the community benefit program, the report must include: Community benefit mission statement approved by the board indicating the target population (and the process used to define it) and objectives and affirming the organizations commitment to addressing the needs of its community and allocating resources to that end Community health needs assessment, including: the health resources in the community and deficiencies in the target population; members of other organizations in the community involved in the assessment; how the assessment was done; and sources of information used Community benefit plan, which describes: the organization and management structure for the program, individuals responsible and qualifications; process and considerations used to determine the budget; process for measuring outcomes and evaluating effectiveness; process for reviewing, evaluating and updating the program; and current activities under the following categories that closely follow those contained in the Catholic Health Associations updated Guide for Planning and Reporting Community Benefit: Subsidized health services Charity care, including policies related thereto Shortfalls in government-sponsored health programs Community health services, including community health education, community-based clinical services and health care support services Health professions education and support Research Financial contributions, including cash donations, grants and in-kind donations of facilities, equipment, food or supplies Community-building activities Other mandated charity care programs Community benefit infrastructure/support costs Other community benefit programs not reported in the forgoing categories The description of the community benefit program must include: Net costs and aggregate contributions by others, both overall and by activity Bad debts must be excluded Medicare losses can only be included if the organization can definitively document that such services were not developed for marketing purposes, the losses are not due to operational inefficiencies, losses in any one program are not offset by gains in any other Medicare program, and there is a negative operating margin greater than five percent Calculations of the total of all net costs for the program as a percentage of total operating revenue (net patient revenue and other revenue) and of total operating expenses Any additional non-quantifiable benefits PAGE  PAGE 2 -HJKLghw+~ '(TyCr3)*:;vw  %%V&W&p<<==??L?M?@@PAQA'B 5>*\>*5\0JCJjgCJU 5>*CJ\ 5CJ\j5CJU\jF UV jULjw *+ } ~  $ & Fa$$a$ll (s23*;w ?nj$ & Fa$$ & Fa$$ & Fa$$ & Fa$$a$O !!"Y##%%%%W&&'/*4+,L-M--v/013E5$ & Fa$$a$$ & Fa$E5Q679:o<p<<<==?M?@QA(B+CbC8DDcE*GGIIJK$ & Fa$$a$$ & Fa$$ & Fa$'B(B*C+CaCbC7D8DDDbEcE)G*GGGIIIIJJKKLLCNDNNN6P7PPPbclllllllllllllllll0JmHnHu0J j0JU 5>*\5\>*4KLDNN7PPPgQ*R SSV/WX[\']`aObbbccXc$ & Fa$$a$$ & Fa$$ & Fa$$ & Fa$Xc`dheegggghhhhi3iXiiij^jyjklllllll$a$$^a$$ & Fa$$ & Fa$$ & Fa$llllllllllh]h&`#$ # 01h/ =!"#$%gDd 0  # AbHN͋56P27DnHN͋56P27PNG  IHDR"xasRGBPLTEꦡ]Lm4t,t<ܮڜ)q<|GVӔ4|xtUGءMWWESrEDT\{~6BDk8i/ r|."N !.X6C-ovP3`N|9UXAoww7s  Yy9/z&bh7(?ɝJc cc+%T'$5o;5i?JBL1N>IYL&)aoIeeR6ƒ7F9y7LZ MJr(H.:/㮑#U 6B76#!hƸ"rZT2s_uy  @Ɓ |(.y3R0\?MJ )g?2|tTCݺs@$1zvnK4 {OsUڶ ?(|P67 JcoS XOt䭣щ{ 7Q ʼG2$$/3YG"fs weYeq.AN2- *QȫH ܿUOO {@ē I ]E.L%ڤؒy?^^Cl^DUdBQ& .z%[5r!k<.yk#죯5%*M{P, |"P7&>r- wzD{mRXϸڻ"W{0 O8c$8g#Y:5T(x"È' V24>ؖf73!]V@v꽷?ė9Sh-"l:׎LuyyXAʰws".MS;H*mɜѽ324RDQvҜ[]=ED^:NoaIxhxǪ~ ɬZDuo[P-#ʛ$r4E$2g& FE(‼(hwM0ծlE۝|T )B+E<6=D,YD4 pNoV " JvkFP:;HoE98rL"DDkVB6Yƈ,4EĞƫXH}IP'ilkƈ@kM.̫5a%%1T&ȝ YmD0qL!M$zy0@ǐ%3`wJAmAa+D(}Zxe/Skjؠ(AvQ3jkS!yWN#Iz#ŋATuZu"K0@1`ԧ!d^IwN#h5tDEJ aB 'n]_"):K|\.F(88딥Fn&j BW+vb;:}#z`*,=yI!*=EF., KP i|rM!b-z]cW/o;7Zf,)n_Nu,"85$uLZB8HQ@"Ƒ]o=~(4;3m,EU,VWpAWκ<0 0'U Ȩ^@xH4"rvLH"+1_y U(3g9 Os86Q '?9D2lFFhpь7fsņc:B%0޺lo6%`)aQ[ޡV){SEC5LM"_"}B_IDz SqU/Ђ  x*e 9A-:3"*S~+gǦ?gB5DA %aK!^QdAl /9g ݳR"&2rHM:,7OoE' h"?C0𢌧̫Ks9X|9۫ 7=K6QSN[tͥ¦\~IfY\l˯qO]QVW¾}p,OyV뢪4aHhPaõ5dODMP✩ru\-XW?V]l$ɵ ]GO3g1}2'/G\&.9  !"#$%&'()*+,-./0123456789:;<=>?@ABCDFGHIJKLORUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry  FQData E\WordDocument %ObjectPool pa_1176027857@96>@)paPsfOle CompObjuObjInfo  @96>@)#Microsoft Photo Editor 3.0 PictureMSPhotoEditor MSPhotoEd.39q9Oh+'0  8 D P \hpxCONTENTS T&CONTENTSV301Table4-SummaryInformation( "x`ꦡ]Lm4t,t<ܮڜ)q<|GVӔ4|xtUG HTѤ9|$۰LrD+W.+ӜHˊX5ݡ4 E6cS­{U7($k-OQLf\ۘ1.d |cXh*6gx ZZ`l+B#IRF&_8ϓingj@ 6VmuRw7:pl0uXtáPB]PG'DαߦLfZНv/J66AR)Ӽ=s)CL|D4Ba8xrLpǼBI :XO6MЬ"D"ux5j"l;0rvDyDYӖgTM2҈(D\0Q=E,##E"89$vszhh$L "RFE!AJ?" k $"!z"A? 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