A refusal to pay policy is not a requirement according to the HRSA Compliance Manual and HRSA OSV Protocol.  In review of Chapter 16: Billing and Collections, Element j, located at https://bphc.hrsa.gov/sites/default/files/bphc/programrequirements/pdf/billing-collections.pdf, a refusal to pay policy is specifically required only IF the health center decides to limit or deny services based on a patient’s refusal to pay.  If a health center decides to deny services to patients that refuse to pay, then the following MUST be in a board-approved policy:

• A clear definition between refusal to pay and inability to pay.  Remember, there is a difference if a patient doesn’t want to pay as opposed to someone who doesn’t have the means to pay
• How the health center notifies patients of the amount owed and the time permitted to pay.  In other words, how will you notify patients of what they owe and what is the timeframe they have to pay it. 
• How the health center notifies patients of collection efforts that will be taken when these situations occur.  So, if a patient refuses to pay, do you let patients know of resources that your health center has?  Examples of resources can be meeting with a financial counselor, establishing  the patient on a payment plan, or offering a prompt pay discount.
• How the health center notifies patients of how services will be limited or denied when it’s determined that the patient refuses to pay.  Will the patient only be allowed to receive emergent care if they are sick, will they be allowed to refill medications if they are diabetic or have high blood pressure?  All these factors must be taken into consideration.

All of these bullets must be included and clearly defined in the policy, and the policy must be board approved.