Implementing Transparent Screening

Financial Assistance disclosures have failed. It’s time for a better way.

At Dollar For, we see it every day: patients burdened by hospital bills they should never have received. Despite federal requirements, only 29% of patients who likely qualify for financial assistance actually receive it.¹ Why? Because financial assistance programs aren’t known, aren’t easy, and aren’t fair.

The current “notice and apply” model places the entire burden on patients—many of whom are sick, stressed, or unaware that help even exists. Instead of relying on passive disclosures, we recommend a proactive solution: transparent screening for every patient. This approach would shift responsibility to hospitals, ensuring that eligible patients are identified and supported before they ever see a bill.

Extensive research shows that medical debt disproportionately affects low- and middle-income patients—the very people financial assistance is designed to help²:

• 12.31% of people below the poverty line have medical debt
• 15.36% of those earning 100–199% of the federal poverty level (FPL)
• 14.75% of those earning 200–299% FPL
• 12.11% of those earning 300–399% FPL

In contrast, just 7.03% of those earning 400% FPL or more carry medical debt._³ Since most hospitals extend assistance up to around 400% FPL⁴, it’s clear that countless eligible patients are slipping through the cracks.

This report outlines why the status quo has failed and how mandatory transparent screening can replace it. It also evaluates real-world tools hospitals can use today to implement a screening model that works.

As the chart below shows, most patients don’t apply for financial assistance because they simply don’t know about it. But this problem runs deeper—many patients assume they won’t qualify or are too confused to navigate the process. Disclosures aren’t enough. We need a system that works for patients, not against them.

Federal law requires nonprofit hospitals to make their financial assistance policies visible and accessible—but visibility does not equal impact. Most patients still don’t know help is available.

Under IRS regulations, tax-exempt hospitals are required to:

• Post their financial assistance policy and application online
• Provide paper copies of the application in person upon request
• Inform the community in ways that are most likely to reach those who need help
• Include a financial assistance notice on every billing statement
• Put up signs in public areas of the hospital to let patients know about available help.⁵

These rules were meant to inform patients, but in practice, they often fail. Notices get buried in stacks of paperwork, hospital websites are confusing and hard to navigate, and patients in the middle of a medical crisis aren’t stopping to read posters in the ER.

The law asks hospitals to disclose. Dollar For believes they must also act.

To create a truly effective financial assistance system, hospitals must move beyond passive notification and implement a proactive approach. Instead of relying on patients to navigate the process themselves, hospitals should adopt transparent screening methods that automatically assess every patient’s eligibility. This would ensure that financial assistance reaches those who need it, removing unnecessary barriers and making healthcare more accessible for all.

Transparent Screening

What is Transparent Screening?

Transparent screening is a proactive process that hospitals should use to assess every patient’s eligibility for financial assistance—before a bill is sent and without requiring the patient to complete an application.

It’s designed to identify as many eligible (or clearly ineligible) patients as early as possible, ideally before discharge. Unlike traditional models that put the burden on patients to know about and apply for assistance, transparent screening shifts responsibility to the hospital to screen every patient as part of the care process.

Some may confuse transparent screening with presumptive eligibility, a process that appears in many hospital policies and federal regulations.⁶ But in practice, presumptive eligibility is often used as a last resort—applied only after repeated billing attempts fail—to decide which patients aren’t worth pursuing for payment, rather than to ensure all eligible patients receive the financial assistance they deserve. The traditional presumptive eligibility prioritizes collections over care.

Transparent screening flips that logic. It’s not about writing off the uncollectible—it’s about identifying, empowering, and helping all eligible patients before debt becomes a threat to their health or stability.

How Would Transparent Screening Work?

Hospitals can build transparent screening into their existing discharge processes with minimal effort. Many already have access to data tools, such as eligibility checks, enrollment in public aid programs, or existing financial technology, that can estimate a patient’s income. Staff should use this data with every patient, to flag potential eligibility and confirm findings with each patient at discharge. Patients would only need to provide documents if clarification or verification is needed later.

It’s also essential that this process respects patient privacy. Any screening must be transparent, consent-based, and clearly communicated, with guardrails to ensure patient data is used only to determine financial assistance eligibility—not for collections or discrimination.

Tools to help implement transparent screening are available at multiple levels:

• Hospitals could adopt this approach today by using existing data tools.
• States could integrate screening into Medicaid and safety-net systems already in place.
• The federal government could expand access to tools like the Income Verification Express System, enabling automatic income checks with patient consent.

The lift is not as heavy as it may seem—the data, the need, and the opportunity are already here.

Transparent Screening Options

Below are tools that could be used independently or combined to create a transparent screening process that works for an individual hospital. There are also options that, with minor policy interventions, have great potential as financial assistance screening tools.

Asking Patients

One of the most effective—and most overlooked—methods of transparent screening is also the simplest: just ask patients about their household income and size.

Data from Oregon shows this approach can be highly effective when paired with existing patient records or data tools. In 2024, Oregon implemented a new law requiring hospitals to screen every patient for presumptive eligibility if they are:

1. uninsured,
2. enrolled in a state medical assistance program, or
3. expected to owe more than $500.⁷

In early 2025, the Oregon Health Authority published a report on the first quarter of hospital implementation. The results were telling: regardless of whether hospitals used more complex tools or methods, those that directly asked the patient about their finances may yield better results. While hospitals that purely screened patients “behind the scenes” were struggling to implement successful screening programs, the reported noted: “One hospital that does not use a software tool reported smooth implementation of their manual pre-screening process, successfully using any existing information on the patient as well as information the patient opted to provide prior to an appointment.”⁸

How and when hospitals ask about a patient’s financial situation is critical. Dollar For conducted focus groups with patients across the country who had navigated the financial assistance process. Most said they were open to sharing income information—but only when they understood how it would be used. Some feared that disclosing financial struggles might lead to being denied care or targeted for collections.

These concerns align with international research. A Canadian study of over 15,000 primary care patients found that 73% voluntarily reported their household income when asked how much they earned and how many people they supported.⁹ For those who hesitated, simple conversations explaining the purpose of the question dramatically increased comfort and participation.¹⁰

The takeaway is clear: Asking patients directly—with empathy, clarity, and purpose—can be both respectful and effective. Hospitals don’t need expensive tools to start screening patients. They need to build trust and ask the right questions, the right way.

Using Large Data Tools To Estimate Income

Some hospitals rely on third-party tools to estimate a patient’s household income and size. These tools pull from a wide range of data sources and vary in how they calculate eligibility.

There are two main categories commonly used in financial assistance screening:

• Credit Rating Tools: These tools are offered by major credit bureaus that aggregate vast amounts of consumer data, from Census records to loan applications, mortgages, and debt profiles.¹¹ They use this data to estimate a patient’s financial situation.
• Historical Data Tools: These rely on proprietary algorithms to estimate income based on public datasets, such as census data, combined with a hospital’s own historical data. Some tools are customized to each hospital’s patient population, refining their accuracy over time.

One advantage of these tools is ease of integration—many connect seamlessly with hospital systems like EPIC, making them attractive for quick deployment. But they come with serious caveats.

When Screening Tools Are Built for Collections

While large data tools can make screening easier for hospitals, most were not designed to expand access to care—they were built to protect revenue. Many of these systems are bundled with broader revenue cycle management services that assess a patient’s “propensity to pay.”

As a result, a patient who qualifies for financial assistance could still be flagged as collectible. In these cases, the tool may nudge the hospital toward pursuing payment instead of applying the discount or forgiveness the patient is owed.

This directly undermines the purpose of financial assistance. When screening tools are guided by profit motives instead of patient need, eligibility can be distorted—and vulnerable patients suffer. These tools can still play a role in a transparent screening process, but only if hospitals implement strong guardrails:

• Financial assistance determinations must be separated from collections scoring.
• Hospitals should audit screening outcomes regularly to check for racial or economic inconsistencies.
• Patients should be able to view and challenge their screening results while in the hospital.

Accuracy and Emerging Tools

Accuracy is another major concern with large data tools. According to the Oregon Health Authority, hospitals that have implemented these tools report they are accurate only about 85% of the time.¹² While that’s a start, it leaves a wide margin for error, especially when real patient lives and finances are on the line.

The same report found that accuracy improves significantly when hospitals pair these tools with direct questions to the patient about their income and household size.¹³ In this model, the tech acts as a secondary check—not the sole decision-maker. When done this way, screening becomes both more precise and more patient-centered. That’s why Dollar For advocates for transparent, patient-first screening practices.

Other Financial Technology Tools (Fintech)

Beyond credit and historical data models, there is a growing category of other financial technology tools. One example is Plaid, a platform that links directly with a user’s bank account (with consent) to verify income.

With tools like this, a patient could securely log in to their online banking during the screening process and allow the system to analyze their income transactions. This could provide an accurate, real-time estimate of annual income—with no paperwork required.

While promising in theory, these tools are not widely used in hospitals today, and little is known about how patients would feel about sharing banking data for this purpose. Any use of fintech in financial assistance screening must prioritize privacy, transparency, and clear consent.

Government-Stored Data

Tax Returns

There are several ways that governments can help hospitals with income verification. Both federal and state governments store large volumes of financial data that could support a transparent screening system. Among the most reliable and widely accepted sources are tax returns. Hospitals already rely on them—most require, or at least accept, a tax return as proof of income during the financial assistance application process. Integrating tax data into screening could significantly reduce the burden on patients to track down and submit documentation themselves.

Federal Tax Returns

Federal law allows for several ways to share tax data—some with patient consent, and others through authorized disclosures for specific programs.

There are two primary categories:

• Specific-purpose disclosures, which can sometimes occur without the taxpayer’s consent.
• General disclosures, which require the taxpayer’s explicit permission.

An example of a specific purpose disclosure is under the Affordable Care Act, the IRS is allowed to share tax return data with health insurers to determine eligibility for insurance subsidies.¹⁴

General disclosures offer even greater flexibility—federal law allows the IRS to send a copy of a taxpayer’s return to any third party, as long as the taxpayer consents.¹⁵ This opens the door to a more streamlined, verified screening process built on government-stored income data, while still protecting patient privacy and control. One way a patient can give this consent is by completing IRS Form 4506, which authorizes a third party, such as a hospital, to access their tax return.¹⁶ However, this approach comes with a drawback: the IRS may charge a significant fee, creating an unnecessary barrier for patients and providers alike.

Another option is IRS Form 8821, which is commonly used by tax professionals—but could also be used to authorize any third party, including hospitals, to access tax information. In fact, the IRS explicitly notes that this form aligns with the “general disclosure” provision of federal tax data law.¹⁷ If a patient signs Form 8821, the hospital could request their tax information directly from the IRS. This approach would avoid the filing fees associated with Form 4506, but it comes with a different challenge: processing can take weeks or even months, delaying the timely application of financial assistance.

There is, however, a faster and more cost-effective option: the Income Verification Express System (IVES). Originally created to help mortgage lenders verify income in near real-time, IVES theoretically could be used to share tax data with any third party, with patient consent.¹⁸ Unfortunately, the IRS currently limits access to mortgage lenders only.¹⁹ If access were expanded to include hospitals, it could dramatically streamline income verification for financial assistance, reducing administrative burdens and speeding up help for patients.

State Tax Returns

A majority of U.S. states collect income tax²⁰—and in doing so, they store valuable financial data that could help hospitals verify income for financial assistance screenings. State-level privacy laws often mirror the federal structure, allowing for limited-use or general disclosures when the taxpayer consents.

In Oregon, for example, any taxpayer can authorize a third party to receive their tax information²¹, and state law requires that tax transcripts requested by a patient’s designee be provided at no cost.²² Many other states offer similar authorization forms that a patient could sign, allowing a hospital to retrieve their return directly,eliminating the need for the patient to dig up tax documents like W-2s or paper filings.

However, the current process is far from streamlined. Most state systems aren’t built for real-time access. In many cases, hospitals must still fax or mail the form to the relevant agency and wait for a manual response. While this is a viable option today, it highlights a significant opportunity for future improvement.

Other Government Sources

The government already maintains multiple tools to verify income eligibility for many programs. Housing Choice Vouchers, SNAP, SSI, and Medicaid programs all use some form of an income screening process that relies on government databases.

Income and Eligibility Verification System

One of the most widely used systems for verifying income eligibility is the Income and Eligibility Verification System (IEVS)—not to be confused with the IVES system used for tax return sharing. IEVS supports programs like SNAP²³, TANF, Medicaid, Unemployment Compensation, and other public benefits²⁴, pulling data from multiple trusted sources including the State Wage Information Collection Agency (SWICA), the Social Security Administration (SSA), the Internal Revenue Service (IRS), and Unemployment Insurance Benefits (UIB).²⁵ This system already plays a critical role in confirming income for millions of people. With modest changes to federal law, IEVS could also be leveraged by hospitals to verify income for financial assistance eligibility, offering a robust, existing solution to streamline and strengthen screening efforts.

Federal Data Services Hub

The Centers for Medicare & Medicaid Services (CMS) operates the Federal Data Services Hub, a centralized system used to verify income eligibility for Medicaid. This single portal connects to multiple authoritative data sources, including Social Security income data, IRS tax records, and employment information from tools like The Work Number.²⁶ Medicaid offices across the country already rely on this hub to quickly and accurately determine eligibility. If hospitals were granted similar access—with patient consent—this existing infrastructure could be a powerful tool for transparent screening in financial assistance programs.

Census and Demographic Data

The U.S. Census Bureau maintains extensive income data across a wide range of demographic variables.²⁷ Tools like the American Community Survey API provide access to median and mean income estimates based on factors such as neighborhood, marital status, homeownership, age, and more.²⁸ In theory, hospitals could use this publicly available data to build a proprietary “trust score”—a tool that helps verify the likelihood that a patient’s self-reported income is accurate by comparing it against demographic norms. While not precise enough to determine eligibility on its own, this kind of tool could be a helpful secondary check in a transparent screening system.

Policy Recommendations

Require Transparent Screening

Transparent screening must become a requirement—not a recommendation. The current “notice and apply” model has failed to deliver relief to the majority of eligible patients, and it never will. Financial assistance policies are meaningless if patients aren’t identified and helped before they incur debt.

Dollar For recommends that statutory language include the following requirements:

• Every patient must be screened for financial assistance eligibility.
• Patients should not be required to provide documents up front, aside from signing basic authorizations.
• Screening must occur before discharge, not weeks or months later.
• Hospitals must review screening results with the patient during or before discharge, giving them the opportunity to confirm or correct any information.

These standards ensure screening happens early, clearly, and with the patient’s knowledge and involvement.

Equip Hospitals with the Right Tools

Mandating transparent screening is only effective if hospitals have the tools to do it well. Legislation must go beyond a blanket requirement and ensure hospitals have access to reliable, accurate systems for income verification.

Policy drafters should:

• Audit existing data tools in their jurisdiction—many already support Medicaid, SNAP, and other public benefit programs.
• Identify legal or regulatory barriers that prevent hospitals from using these tools for financial assistance—and remove them.
• Expand access to internal government APIs or data repositories that currently serve only state agencies or contractors.
• Encourage innovation around privacy-protected, real-time verification tools—especially those that reduce paperwork for patients.

With the right systems in place, transparent screening can be implemented quickly, accurately, and equitably—ensuring patients get the help they’re entitled to without unnecessary delay.

Conclusion

No patient should leave the hospital unsure about whether they qualify for financial assistance—or worse, unaware that help exists at all. Hospitals have the power to fix this now. Hospitals have the capability to screen every patient before discharge, yet most still don’t. At the very least, they could ask patients about their financial situation. The fact that so few do is proof that voluntary disclosure isn’t enough. We need policy that makes transparent screening the standard.

But policy alone isn’t the answer. Hospitals must also be set up to succeed. That means building systems that are patient-centered, consistent, and rooted in existing tools already used for programs like Medicaid and SNAP. With thoughtful legislation and practical infrastructure, we can ensure every patient is screened fairly, early, and accurately—so no one falls through the cracks.

Endnotes

1. Goldstein, Elise, et al. “The Path to Charity Care.” Dollar For, April 2024, https://dollarfor.org/wp-content/uploads/2024/04/Dollar_For_Path.pdf. Accessed 5 May 2025.
2. (Goldstein et al.)
3. Himmelstein, David U., et al. “Prevalence and Risk Factors for Medical Debt and Subsequent Changes in Social Determinants of Health in the US.” Jama Network Open, 16 September 2022, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2796358. Accessed 5 May 2025.
4. Messac, Luke, et al. “US Nonprofit Hospitals Have Widely Varying Criteria To Decide Who Qualifies for Free and Discounted Care.” Health Affairs, November 2024, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2023.01615. Accessed 5 May 2025.
5. 26 C.F.R. 501(r)-4(b)(5).
6. See 26 C.F.R. 501(r)-6(c)(2).
7. ORS 442.615(2).
8. Oregon Health Authority. “Prescreening Hospital Interview Summary_FINAL.” Oregon.gov, January 2025, https://www.oregon.gov/oha/HPA/ANALYTICS/HospitalReporting/Hospital%20Prescreening%20Implementation%20Interview%20Summary.pdf. Accessed 5 May 2025.
9. Pinto, Andrew David, et al. “Routinely Asking Patients About Income in Primary Care: A Mixed-Methods Study.” BJGP Open, 12 January 2022, https://pmc.ncbi.nlm.nih.gov/articles/PMC8958735/. Accessed 5 May 2025.
10. (Pinto et al.)
11. (Oregon Health Authority)
12. (Oregon Health Authority)
13. (Oregon Health Authority)
14. 26 U.S.C. 6103(l)(18)
15. 26 U.S.C. 6103(c)
16. IRS. Form 4506. 2024. About Form 4506, Request for Copy of Tax Return, https://www.irs.gov/forms-pubs/about-form-4506.
17. IRS. Instructions for Form 8821 (09/2021). 2021. irs.gov, https://www.irs.gov/instructions/i8821.
18. IRS. Income Verification Express Service. 2024. irs.gov, https://www.irs.gov/individuals/income-verification-express-service.
19. American Banker’s Association. “Joint Comments to Congress on the IRS Blocking Access to Income Verification System.” aba.com, 2024, https://www.aba.com/advocacy/policy-analysis/joint-comments-ives. Accessed 5 May 2025.
20. Yushkov, Andrey. “2024 State Income Tax Rates and Brackets.” Tax Foundation, 20 February 2024, https://taxfoundation.org/data/all/state/state-income-tax-rates-2024/. Accessed 5 May 2025.
21. ORS 305.193; ORS 314.840.
22. OAR 150-192-0400
23. 7 CFR 727.8(a)(1)
24. 42 USC 1320b-7(b)
25. 7 CFR 272.8(a)(1)(i)-(iv)
26. GAO. “21-183, Accessible Version, FEDERAL LOW-INCOME PROGRAMS: Use of Data to Verify Eligibility Varies Among Selected Programs an.” GAO, 25 February 2021, https://www.gao.gov/assets/720/712658.pdf. Accessed 5 May 2025.
27. Census Bureau. Census API. 2025. Census Data, https://api.census.gov/data.html.
28. Census Bureau. Census Data API Variables. 2025. Census Data API, https://api.census.gov/data/2022/acs/acs5/subject/variables.html.