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Thread: fees

  1. #1
    Join Date
    Apr 2007
    Syracuse New York

    Question fees

    AAPC: Back to School
    I work for an internist. We, where applicable, extend professional courtest for co-pays (fine and dandy, legalities understood). However, we do not give discounts to patients who are self pay. We have a set fee schedule for workers compensation and then one for the rest (insured/self-pay). Reason being, we are under the impression that a fee schedule is a fee schedule and we have to charge the same for each procedure no matter what.

    My question arises from something that I heard. Of course you want to be able to help your patients out, however, it needs to be within our rights to provide such a benefit.

    Sooo... if this is something you are able to do I'd like any information on where I can find it in writing and wha guidelines there are because I don't this would be some percentage you can just come up with. ANY ADVICE WOULD BE SO... HELPFUL! Thank you so so much!

  2. #2
    Join Date
    Apr 2007
    Albany, NY

    Smile Careful.

    Let me start by saying that it is likely a breach of contract with the insurances you par with to write off copays or extend "professional courtesy".

    Here's a bit about coinsurances and deductibles that you may find interesting if it's applicable, but as for your question about self-pay...you can do anything you want--discount-wise--when there is no insurance in play. You are not required to collect your full-charge amount for self-pay patients.

    Now for the other stuff:

    What Are Medicare Deductible and Copayment Charges?

    The Medicare ``deductible'' is the amount that must be paid by a
    Medicare beneficiary before Medicare will pay for any items or services
    for that individual. Currently, the Medicare Part B deductible is $100
    per year.
    ``Copayment'' (``coinsurance'') is the portion of the cost of an
    item or service which the Medicare beneficiary must pay. Currently, the
    Medicare Part B coinsurance is generally 20 percent of the reasonable
    charge for the item or service. Typically, if the Medicare reasonable
    charge for a Part B item or service is $100, the Medicare beneficiary
    (who has met his [or her] deductible) must pay $20 of the physician's
    bill, and Medicare will pay $80.

    Why Is it Illegal for ``Charged-Based'' Providers, Practitioners and
    Suppliers to Routinely Waive Medicare Copayment and Deductibles?

    Routine waiver of deductibles and copayments by charge-based
    providers, practitioners or suppliers is unlawful because it results in
    (1) false claims, (2) violations of the anti-kickback statute, and (3)
    excessive utilization of items and services paid for by Medicare.
    A ``charge-based'' provider, practitioner or supplier is one who is
    paid by Medicare on the basis of the ``reasonable charge'' for the item
    or service provided. 42 U.S.C. 1395u(b)(3); 42 CFR 405.501. Medicare
    typically pays 80 percent of the reasonable charge. 42 U.S.C.
    1395l(a)(1). The criteria for determining what charges are reasonable
    are contained in regulations, and include an examination of (1) the
    actual charge for the item or service, (2) the customary charge for the
    item or service, (3) the prevailing charge in the same locality for
    similar items or services. The Medicare reasonable charge cannot exceed
    the actual charge for the item or service, and may generally not exceed
    the customary charge or the highest prevailing charge for the item or
    service. In some cases, the provider, practitioner or supplier will be
    paid the lesser of his [or her] actual charge or an amount established
    by a fee schedule.
    A provider, practitioner or supplier who routinely waives Medicare
    copayments or deductibles is misstating its actual charge. For example,
    if a supplier claims that its charge for a piece of equipment is $100,
    but routinely waives the copayment, the actual charge is $80. Medicare
    should be paying 80 percent of $80 (or $64), rather than 80 percent of
    $100 (or $80). As a result of the supplier's misrepresentation, the
    Medicare program is paying $16 more than it should for this item.
    In certain cases, a provider, practitioner or supplier who
    routinely waives Medicare copayments or deductibles also could be held
    liable under the Medicare and Medicaid anti-kickback statute. 42 U.S.C.
    1320a-7b(b). The statute makes it illegal to offer, pay, solicit or
    receive anything of value as an inducement to generate business payable
    by Medicare or Medicaid. When providers, practitioners or suppliers
    forgive financial obligations for reasons other than genuine financial
    hardship of the particular patient, they may be unlawfully inducing
    that patient to purchase items or services from them.
    At first glance, it may appear that routine waiver of copayments
    and deductibles helps Medicare beneficiaries. By waiving Medicare
    copayments and deductibles, the provider of services may claim that the
    beneficiary incurs no costs. In fact, this is not true. Studies have
    shown that if patients are required to pay even a small portion of
    their care, they will be better health care consumers, and select items
    or services because they are medically needed, rather than simply
    because they are free. Ultimately, if Medicare pays more for an item or
    service than it should, or if it pays for unnecessary items or
    services, there are less Medicare funds available to pay for truly
    needed services.
    One important exception to the prohibition against waiving
    copayments and deductibles is that providers, practitioners or
    suppliers may forgive the copayment in consideration of a particular
    patient's financial hardship. This hardship exception, however, must
    not be used routinely; it should be used occasionally to address the
    special financial needs of a particular patient. Except in such special
    cases, a good faith effort to collect deductibles and copayments must
    be made. Otherwise, claims submitted to Medicare mat violate the
    statutes discussed above and other provisions of the law.

    What Penalties Can Someone Be Subject to for Routinely Waiving
    Medicare Copayments or Deductibles?

    Whoever submits a false claim to the Medicare program (for example,
    a claim misrepresents an actual charge) may be subject to criminal,
    civil or administrative liability for making false statements and/or
    submitting false claims to the Government. 18 U.S.C. 287 and 1001; 31
    U.S.C. 3729; 42 CFR 1320a-7a). Penalties can include imprisonment,
    criminal fines, civil damages and forfeitures, civil monetary penalties
    and exclusion from Medicare and the State health care programs.
    In addition, anyone who routinely waives copayments or deductibles
    can be criminally prosecuted under 42 U.S.C. 1320a-7b(b), and excluded
    from participating in Medicare and the State health care programs under
    the anti-kickback statute. 42 U.S.C. 1320a-7(b)(7).
    Finally, anyone who furnishes items or services to patient
    substantially in excess of the needs of such patients can be excluded
    from Medicare and the State health care programs. 42 U.S.C. 1320a-

    Indications of Improper Waiver of Deductibles and Copayments

    To help you identify charge-based providers, practitioners or
    suppliers who routinely waive Medicare deductibles and copayments,
    listed below are some suspect marketing practices. Please note that
    this list is not intended to be exhaustive but, rather, to highlight
    some indicators of potentially unlawful activity.
    Advertisements which state: ``Medicare Accepted As Payment
    in Full,'' ``Insurance Accepted As Payment in Full,'' or ``No Out-Of-
    Pocket Expense.''
    Advertisements which promise that ``discounts'' will be
    given to Medicare beneficiaries.
    Routine use of ``Financial hardship'' forms which state
    that the beneficiary is unable to pay the coinsurance/deductible (i.e.,
    there is no good faith attempt to determine the beneficiary's actual
    financial condition).
    Collection of copayments and deductibles only where the
    beneficiary has Medicare supplemental insurance (``Medigap'') coverage
    (i.e., the items or services are ``free'' to the beneficiary).
    Charges to Medicare beneficiaries which are higher than
    those made to other persons for similar services and items (the higher
    charges offset the waiver of coinsurance.)
    Failure to collect copayments or deductibles for a
    specific group of Medicare patients for reasons unrelated to indigency
    (e.g., a supplier waives coinsurance or deductible for all patients
    from a particular hospital, in order to get referrals).
    ``Insurance programs'' which cover copayments or
    deductibles only for items or services provided by the entity offering
    the insurance. The ``insurance premium'' paid by the beneficiary is
    insignificant and can be as low as $1 a month or even $1 a year. These
    premiums are not based upon actuarial risks, but instead are a sham
    used to disguise the routine waiver of copayments and deductibles.
    D. Special Fraud Alert: Hospital Incentives to Physicians
    (Issued May 1992)

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