Do's and Don'ts for Patient Financial Assistance Programs

Risks associated with any particular patient financial assistance program (such as free or discounted lodging, transportation, and other financial assistance) would be a fact-based analysis. However, given the existing federal and state fraud and abuse laws and sub-regulatory guidance, we generally recommend incorporating as many of the below regulatory guardrails as possible into such programs, to the extent appropriate for the program, in order to protect against regulatory scrutiny:

• Do conduct patient assistance programs in a manner that does not encourage overutilization or steer patients to the health care provider or supplier (programs should generally only be open to patients who have already chosen the health care provider or supplier as their provider of services, as opposed to offering assistance only to new patients).
• Do offer assistance on an equitable basis, rather than only to patients likely to be more lucrative for the health care provider or supplier.
• Do provide patient assistance to a narrow pool of eligible patients and their families, such as patients with a demonstrated financial need (e.g., household income at or below 400% of the federal poverty level), when appropriate.
• Do impose imitations on the number of times assistance under a particular patient assistance program will be provided to a patient and/or family in a given time period (e.g., semi-annually).
• Do institute an annual cap, per patient, on the monetary value of the various forms of assistance it offers under patient assistance programs (e.g., no more than $500 total per patient annually).
• Do offer lodging and transportation assistance only to patients and their families who live certain distances from the health care provider or supplier facility (e.g., outside of a 25-mile radius for lodging assistance, and inside of a 25-mile radius for transportation assistance).
• Do inform patients receiving assistance of their right to choose any health care provider.
• Do ensure that patient assistance programs do not shift costs to any federal health care program.
• Do pay the costs or any items or services provided to a patient directly to the vendor, when possible.
• Do closely monitor programs to ensure that (i) they are achieving the goals of the programs (e.g., aiding financially needy patients, addressing social determinants of health and reducing health care costs for eligible patients), and (ii) the programs are not resulting in increased utilization.
• Do develop and implement written, uniform policies that codify the patient assistance programs, outline the processes and eligibility criteria for patients, and ensure that the programs are offered in a manner that incorporates these regulatory guardrails.
• Do not provide cash or cash equivalents to patients.
• Do not advertise any program assistance to potential or actual patients in the community.
• Do not condition availability of program assistance on a patient’s payor source.
• Do not condition program assistance on the types of services a patient seeks.
• Do not track referrals or revenue generated from patients receiving assistance from patient assistance programs.