Follow-ups with patient's responsibilty

[aangita]

Hello,

I have looked over several posts but cannot seem to find one that answers my questions specifically.

Our clinic extends copay/pt. resp. waivers for follow up visits. (or policy is within 7 days of last DOS). That could include re-checks, suture removals, or incorrect lab testing, etc.
Most of the times the visits do not last very long (under 10-15 minutes), but sometimes the doctors do see the patient for a bit longer than that and attempt to treat them further if what was treated on the previous DOS did not work.

For our staff that has insurance, they waive the copay/pt resp. and bill the insurance as well. I am told that if you do that, the visit should be waived in its entirety and not billed to the insurance company—but if you have a contract with the insurance company, every visit needs to be billed to them.

As I learn about billing and coding compliances and laws, I am realizing that this is fraud and I want to raise these issues with the doctors and the other billing staff.

My question is, if a clinic wants to extend follow up waivers to their patients (or waivers in general to their employees and families w/ INS) how can they do that legally without violating their insurance contract or breaking any federal law?

[marina@medibright.com]

You are absolutely right , you are not allowed to bill an insurance company if you are not collecting a copay. Insurance companies use copayments to share health care costs.

[drakena74]

Your right. If your contracted with an insurance you have to collect all copays, coinsurance, &/or deductibles from the patients.

I'm not sure what state your in, but in California we have the CMA (California Medical Association) that we can call for questions like these or even the AMA may have answers too.

[dclark7]

You do not need to bill every visit to the insurance company. If you choose to waive the charges, the visit must be documented in the patients' records, but you do not have to send a claim to the insurance. Since you are not requesting any payment from them there is no breach of contract in not sending a claim. To get more information regarding waiving copays/deductibles you can go to the OIG website www.oig.gov.

[honeybee]

I agree with my fellow posters, if you are going to routinley waive those types of services you need to do a non-billable type of encounter so you still have the record of the service provided in the patients chart but not bill the insurance since this is against the contracts.

I thought the only situation you could bill but waive patient responsiblities is if a financial hardship is on file and is substantiated by info the patient has provided? Is anyone familar with this