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Billing one payer but not another?

  1. Default Billing one payer but not another?
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    Advice please- Our clinic performs a neck and abdominal ultrasound with every physical we perform. We do not want our patients to ever have to pay for these services. Recently we have discovered that one of the major payers in our area will pay for the services where the others do not (deductible). Is there any legal or ethical question in billing it only to the payer that WILL pay for the service and not billing the others?


  2. #2
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    Quote Originally Posted by wjune66 View Post
    Advice please- Our clinic performs a neck and abdominal ultrasound with every physical we perform. We do not want our patients to ever have to pay for these services. Recently we have discovered that one of the major payers in our area will pay for the services where the others do not (deductible). Is there any legal or ethical question in billing it only to the payer that WILL pay for the service and not billing the others?

    If I understand correctly, you're asking if it is permissible to offer a given service at no charge to certain patients, but at a charge to other patients, on the basis of whether or not their insurance plans are expected to issue a payment for that service, is that correct? If that's the case, although it is perhaps well-intended, I would consider this to be of questionable ethics and almost certainly not compliant since it is essentially constitutes discrimination based on a patient's level of insurance coverage. It could in fact be illegal discrimination as well, and potentially in violation of any payer contracts you may have, but I would defer to an attorney licensed in your state of practice to make that determination. In addition, deductibles and patient share exist in the healthcare industry in order to help control costs and to involve patients in the decisions about whether or not to consume healthcare services - offering services for free to patients to allow them to avoid those costs could also be considered a potentially illegal inducement to those patients to consume additional covered services which in turn increases costs to payers. I strongly recommend your practice not do this.

    It is laudable that your providers want to help make care more affordable to patients, but this is not the correct way to go about it. A better approach instead would be to create a compliant financial hardship policy or generous charitable care program to get the assistance to those patients that need it most.
    Last edited by thomas7331; 08-30-2018 at 02:27 PM.
    Thomas Field, CPC, CEMC

  3. Default thank you
    Thank for your reply. Do you know of a site that may have this information? I would like to give it to my CFO to support my stance on the subject.

  4. #4
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    Here are a few:

    From HCPro: http://www.hcpro.com/HIM-60089-859/S...-the-same.html

    From the OIG, regarding inducements to beneficiaries: https://oig.hhs.gov/fraud/docs/alert...nducements.pdf

    A good related FAQ article from UW Medicine's compliance site: http://depts.washington.edu/comply/r...ducement-faqs/
    Thomas Field, CPC, CEMC

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