Wiki Prioritizing Payers

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Hi everyone,

I currently work at a physical therapy clinic in Los Angeles, CA, and we are very, very busy. My boss is asking me if we would have any compliance/legal issues if we were to prioritize payers? Meaning we would hold spots for certain payers? I just don't feel good about this practice.
 
Hmmm. I have not heard of any regulation that would stop you from doing so. I mean it's your business, you can choose to not accept new patients if you wish. You can also choose not to schedule new appointments for patients with "inferior" payers if you think that'll result in higher overall reimbursement from the appointments that you do keep. Plenty of providers don't accept patients with particular insurance coverage.

However, as an existing patient I would be very upset if my doctor told me that the wait for an appointment would be longer because of my insurance. I would seek another doctor, personally. Better figure a way to describe the scheduling difficulty as something other than an insurance-based decision, or you're likely to lose patients. As much as I'd like to think that providers treat all patients the same regardless of their insurance, I have experienced first hand a provider trying to upsell testing services that were not necessary, simply because he knew my insurance would cover it.

In short, I think it's unethical, but not illegal. If you've got more business than you can handle and your provider is still trying to find ways to make more profit, he isn't worried about patient outcomes, he's worried about the mortgage on his second home. That may come off a bit judgmental, but honestly, that's a greedy bugger.
 
As this is a legal question and unless you are an attorney, I would strongly recommend you not try answer this question for your boss, and would also recommend against taking seriously any kind of legal advice from a forum response. Really this a question your bosses should be asking their practice attorneys, not their staff. To give priority to patients of certain payers could be viewed as a form of discrimination, and there could well be local or state regulations that prohibit this sort of thing. This could also potentially put your practice in breach of some of your existing payer contracts. Best to refer this to someone who has a qualified knowledge of the relevant laws and who can review your practice's agreements and make an appropriate and informed recommendation.
 
As this is a legal question and unless you are an attorney, I would strongly recommend you not try answer this question for your boss, and would also recommend against taking seriously any kind of legal advice from a forum response. Really this a question your bosses should be asking their practice attorneys, not their staff. To give priority to patients of certain payers could be viewed as a form of discrimination, and there could well be local or state regulations that prohibit this sort of thing. This could also potentially put your practice in breach of some of your existing payer contracts. Best to refer this to someone who has a qualified knowledge of the relevant laws and who can review your practice's agreements and make an appropriate and informed recommendation.
I took it as a given that they weren't under contract with they payers they'd be excluding. Obviously if you have a contract with a particular payer, the situation changes. It would be, as you say, a legal matter where you'd defer to the contract. I'm not an attorney, I should say, and I'm also not in California, so I'm not going to be privy to any local regulations. However, the point I made about not accepting particular insurances is still valid - providers don't have to accept an insurance that they're not contracted with. I agree though, that the matter shouldn't be decided by anyone without knowledge of the relevant regulations and contracts.
 
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