Wiki creating a cash fee for patients w/o ins or maxed benefits

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gramyanniejoe

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anyone have an idea how to set a fee schedule for patients with out insurance or maxed benefits that would comply within the stark and anti kickback laws and would not be in conflict with insurance companies or effect current payment reimbursements? My office is trying to obtain information to give cash patients a break but also wants to be complient..Everyone has their own idea.. and no one agrees....
Thanks
Shirley CPC:rolleyes:
 
Recently, the OIG published a guideline called, "A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse" that sets straight a common misunderstanding about setting lower fee schedules for self-pay patients. See the booklet here on page 5: http://oig.hhs.gov/fraud/PhysicianEducation/

The verbiage is this: "It is also legal to provide free or discounted services to uninsured people."

Depending on your patient population, some practices may want to set the fees at the Medicare level, or others may feel nominal fees are appropriate.
 
gramyanniejoe said:
anyone have an idea how to set a fee schedule for patients with out insurance or maxed benefits that would comply within the stark and anti kickback laws and would not be in conflict with insurance companies or effect current payment reimbursements? My office is trying to obtain information to give cash patients a break but also wants to be complient..Everyone has their own idea.. and no one agrees....
Thanks
Shirley CPC:rolleyes:
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What my offices do it use the medicare fee schedule and then multiply that by 1.5 for a self pay rate. Medicare fee schedules are published so they are a good base for your fee schedule formula. Some offices go to a factor of 3 times the medicare fee schedule depending on their office costs and area.

But using a base such as medicare is always a good idea because the relative values are based on research and are well laid out and readily available.

As long as you have consistency- making sure that any discounts are applied across the board to all patients using a standard-(no discounts for physicians only for example), you can determine your own fee schedule. For patients who are going to receive a reduced rate, have a written policy and/or income guidelines to show that you are not providing favored status to a particular patient.
 
Discounts

We automatically offer all self-pay patients a 10% discount off our fee schedule.
We offer an additional 10% for prompt pay ... i.e. in full at time of first statement (so a total of 20% discount).

For patients with financial harship ... there is a process they must complete, which includes providing detailed financial information (pay stubs, tax records, etc). The total of their income vs expenses is examined and a discount provided based on the results. A few of these patients will qualify for a 100% discount (more typically about 40%). BUT ... they have to complete ALL the paperwork to qualify. Patients who are not willing to be open about their financial records are still gien the automatic 10% discount (or 20% for prompt pay).

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Budget Plans

Another option we offer patients who are self-pay (over an above any discount they may be entitled to) ... or who have a large balance due after insurance ... is a budget payment plan.

Again, full financial disclosure is required for this ... but we will set up a very reasonable payment plan and not charge interest. We have patients who are paying as little as $25 a month on significant balances (i.e. it will take them 5+ years to pay it off).

A relatively small number of patients take advantage of this. Most people do not want to provide the full financial disclosure.

In any approach a pratice taeks, it is best if you have a financial manager who handles this. Doctors should NOT be diagnosing their patient's wallets ...

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
..on this same topic - I am curious and would like written documentation to lean on - for insurance plans that we have a contractual agreement with (i.e. BCBS, AETNA, UHC) .. in which we accept their fee schedules .. I know we cannot reduce the amount a patient owes if the monies were applied to deductible, but, what about coins? Can that be reduced further without being in violation? I have a new office manager who has advised our billing company for ALL patients who request a reduction - they are to give them a 20% discount. I was under the impression that it was not legal since we have a legal binding contract with the insurance company. Anyone?
 
Carolyn,

There is a contractual obligation between the health plan member (patient) and the health plan indicating the member is responsible for all applicable copays, coinsurance, and deductibles. It doesn't matter whether it's commercial or Medicare.

Generally, you should not reduce these monies owed unless you have already performed a good faith effort to collect (and can prove it). The general rule is 3 billing cycles but many people will go 6 or 8. Even then, you should require evidence of a hardship in order to reduce or write off what is owed, especially when it's the three items I mentioned above.

It is in writing somewhere and when I find it, I will share with you. Perhaps someone else reading this post has the info at their fingertips and will share.
 
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