Terms & Conditions
Effective August 2, 2025
Self-Pay, Uninsured Patient Billing & Financial Responsibility Policy
This policy defines the financial responsibilities of patients who receive hospital services without health insurance or third-party coverage.
Effective Date
August 2, 2025
Revenue Cycle / Patient Financial Services
1. Purpose
E Medical Center (“Hospital”) establishes this policy to define the financial responsibility of patients who receive hospital services without health insurance or other third-party coverage.
Establish a consistent self-pay pricing adjustment for uninsured patients
Clearly disclose the patient’s financial responsibility
Establish eligibility requirements for additional financial assistance
Establish billing and payment procedures
Comply with applicable Virginia and federal requirements governing uninsured patients, financial assistance, and medical-debt collection
This policy does not limit any right or protection provided to a patient by applicable federal or Virginia law.
2. Definition of an Uninsured / Self-Pay Patient
For purposes of this policy, an Uninsured Patient is a patient who does not have:
- Applicable health insurance
- Governmental medical assistance
- Third-party coverage
- Workers’ compensation coverage
- Automobile medical payment coverage
- Another source of payment for the services provided
Screening Requirement
The Hospital will make reasonable efforts to determine whether an uninsured patient may qualify for Medicaid or other applicable medical assistance, and whether the patient qualifies for financial assistance under this policy, as required by Virginia law.
3. Standard Self-Pay Adjustment
standard pricing adjustment for qualifying uninsured patients, calculated against gross charges for eligible services.
Example Calculation
| Item | Amount |
|---|---|
| Hospital charges | $18,500 |
| Standard adjustment (20%) | ($3,700) |
| Adjusted patient balance | $14,800 |
The adjusted balance constitutes the patient’s financial responsibility unless the patient subsequently qualifies for additional financial assistance, an applicable government program, a legally required adjustment, or another discount expressly authorized by the Hospital.
4. Nature of the Self-Pay Adjustment
The 20% pricing adjustment is a standard accommodation for qualifying uninsured patients.
Not this
Not a determination of financial indigence
Not this
Does not constitute charity care
Not this
Does not guarantee additional assistance
Unless otherwise required by law or expressly approved under this policy, the Hospital is not required to provide an additional discretionary reduction solely because a patient is unable or unwilling to pay the remaining balance.
5. Financial Assistance
The Hospital maintains a separate Financial Assistance Policy (FAP) establishing the circumstances under which patients may qualify for free or additional discounted care.
Eligibility Documentation
6. Patients Who Do Not Qualify for Additional Financial Assistance
If a patient does not qualify for additional assistance, the remaining account balance shall remain the patient’s financial responsibility.
| Item | Amount |
|---|---|
| Applicable hospital charges | $18,500 |
| Standard adjustment | ($3,700) |
| Remaining patient responsibility | $14,800 |
7. No Automatic Additional Reduction
The Hospital does not guarantee an additional reduction after application of the standard 20% pricing adjustment.
8. Patient Billing
The Hospital shall provide the patient with a billing statement identifying, as applicable: services provided; applicable charges; the self-pay adjustment; adjustments; payments received; the remaining balance; available financial-assistance information; information concerning applicable payment-plan rights; and instructions for requesting financial assistance or disputing the bill.
9. Payment Plans
Where Virginia law requires the Hospital to offer a payment plan, the Hospital shall provide such plan in accordance with applicable law.
10. Payment-Plan Renegotiation
A patient participating in a payment plan subject to Virginia’s statutory payment-plan protections may request renegotiation. The Hospital shall provide the renegotiation opportunity required by applicable law.
Factors considered: household income, employment, household size, financial circumstances, medical circumstances, existing payment obligations, and other relevant financial information.
11. Failure to Pay
If a patient does not pay the balance according to the applicable billing terms or an agreed payment arrangement, the Hospital may pursue lawful collection remedies available under applicable federal and Virginia law.
Virginia currently prohibits a general hospital from taking certain extraordinary collection actions to recover medical debt unless it has first made all reasonable efforts to determine whether the patient qualifies for medical assistance or financial assistance.
12. Patient Cooperation
The Hospital may deny or discontinue assistance where permitted by law if the patient:
- Provides materially false or incomplete information
- Fails to provide reasonably requested eligibility documentation
- Fails to make good-faith efforts to obtain applicable insurance or governmental assistance
- Fails to comply with an applicable payment arrangement
13. Billing Disputes
A patient may request an itemized statement and may dispute an amount believed to be incorrect. The Hospital shall investigate legitimate billing disputes and correct verified billing errors.
A billing dispute does not automatically cancel the patient’s undisputed financial responsibility.
14. Emergency Services
Nothing in this policy shall be interpreted to permit the Hospital to deny or delay emergency medical screening or emergency treatment based upon a patient’s inability to pay where prohibited by applicable federal or state law.
15. Non-Discrimination
Financial-assistance determinations shall be administered consistently and without unlawful discrimination.
16. No Waiver of Statutory Rights
Nothing in this policy shall be interpreted as waiving any right under Virginia or federal law. Where a provision conflicts with applicable law, applicable law shall control.
17. Financial Responsibility Agreement
At registration, the Hospital may require an uninsured patient or financially responsible party to acknowledge the Hospital’s applicable financial terms.
“I understand that I am financially responsible for charges associated with services provided by E Medical Center for which no third-party payment source is available. I understand that qualifying uninsured patients may receive the Hospital’s applicable 20% pricing adjustment. I understand that additional financial assistance is subject to eligibility under the Hospital’s Financial Assistance Policy and applicable law. I understand that any remaining balance after applicable adjustments, payments, and financial assistance remains my responsibility, subject to my rights under applicable federal and Virginia law.”
18. Examples of Application
Scenario A — Self-pay adjustment only
| Hospital charges | $18,500 |
| Adjustment (20%) | $3,700 |
| Patient responsibility | $14,800 |
Balance remains due if the patient does not qualify for additional assistance.
Scenario B — Additional assistance approved
| Hospital charges | $18,500 |
| Adjustment (20%) | $3,700 |
| Remaining balance | $14,800 |
| Approved assistance | $8,500 |
| Final patient responsibility | $6,300 |
Additional assistance reduces the patient’s responsibility to $6,300.
Scenario C — Billing error
| Hospital charges | $18,500 |
| Adjustment (20%) | $3,700 |
| Patient balance | $14,800 |
| Corrected charges | $16,200 |
| Adjusted balance | $12,960 |
The Hospital shall not seek payment of charges determined to be invalid or incorrectly billed.
20. Policy Administration
Responsible Department
Revenue Cycle Department
Review Frequency
At least annually and when material changes occur
The Hospital’s Compliance Officer and Legal Department shall periodically review this policy to ensure continued compliance with changes in Virginia law, Virginia Department of Health regulations, federal law, Medicare/Medicaid requirements, consumer-protection requirements, and medical-debt collection requirements.
Legal Basis and Governing Law
This policy is intended to operate consistently with Virginia’s current statutory and regulatory framework governing uninsured patients and hospital financial assistance.
Screening Requirement
Virginia law requires hospitals to make reasonable efforts to screen uninsured patients for medical assistance and financial assistance. It does not, by itself, establish a universal percentage adjustment that every uninsured patient must receive.
Publication Requirement
Virginia also requires hospitals to publish and provide information concerning charity care and discounted care, including eligibility criteria and application procedures.
General Terms and Conditions
Acceptance
By receiving services from E Medical Center, the patient or financially responsible party agrees to be bound by this policy and the Hospital’s standard terms of service.
Modifications
E Medical Center reserves the right to modify this policy at any time. Material changes will be communicated through updated billing statements or other written notice.
Severability
If any provision of this policy is held to be invalid or unenforceable by a court of competent jurisdiction, the remaining provisions shall remain in full force and effect.
Entire Agreement
This policy, together with the Hospital’s Financial Assistance Policy, constitutes the entire agreement between the patient and the Hospital regarding financial responsibility for services rendered.
Contact Information
For questions regarding this policy, financial assistance, or billing disputes, contact:
E Medical Center
Patient Financial Services Department
Revenue Cycle Department
[Hospital Address]
[Phone Number]
[Email Address]
Policy Review and Compliance
This policy is adopted as the official financial responsibility standard for uninsured and self-pay patients at E Medical Center. The Hospital’s Compliance Officer and Legal Department shall periodically review this policy to ensure continued compliance with changes in Virginia law, Virginia Department of Health regulations, federal law, Medicare/Medicaid requirements, consumer-protection requirements, and medical-debt collection requirements. Where this policy conflicts with applicable law, applicable law shall control.