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Is this ethical?

  1. #1
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    Aberdeen, SD
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    Default Is this ethical?
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    Our doctor saw a patient/friend/relative in the office and did two minor procedures. The doctor didn't charge the patient. The patient now wants us to submit a statement showing the CPT codes with zero dollar amounts to a supplemental policy, which he/she states will pay the patient for any hospital stays or surgeries. We didn't submit this to the patients health INS and we are contracted with them. We are not sure how these type of supplemental policies work. Can we get in trouble from the health INS co for not filing? Ethically can we do this? Thank you.

  2. #2
    Location
    Tacoma, WA
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    Quote Originally Posted by sjsantjer View Post
    Our doctor saw a patient/friend/relative in the office and did two minor procedures. The doctor didn't charge the patient. The patient now wants us to submit a statement showing the CPT codes with zero dollar amounts to a supplemental policy, which he/she states will pay the patient for any hospital stays or surgeries. We didn't submit this to the patients health INS and we are contracted with them. We are not sure how these type of supplemental policies work. Can we get in trouble from the health INS co for not filing? Ethically can we do this? Thank you.
    Sounds like an AFLAC type policy that pays their clients personally for certain medical circumstances. They are not in any way tied to the patient's regular medical insurance. This type of policy would pay whether the patient's medical insurance was billed and paid, or not. The patient is asking for exactly what took place, a statement showing the CPT code for the procedure done with a $0 amount as no billing was sent.

    Doctors are allowed to provide free care at their discretion, most do not as it is not good for the bottom line. This is considered professional courtesy. The unethical part would be if the doctor billed medical insurance for a friend or relative, and then wrote off the difference that was considered patient responsibility.

    From the AMA website:
    "Physicians should exercise caution in extending professional courtesy where the patient may be in a position to make referrals. If the physician's intent behind extending professional courtesy is to generate referrals for Medicare or Medicaid covered services, the government will be in a position to prosecute a fraud or abuse case for a violation of the anti-kickback law.

    Extensive research has failed to uncover any instance where a physician has been prosecuted by either the OIG or the DOJ for fraud or abuse based on the extension of professional courtesy. Furthermore, the OIG is unlikely to initiate a fraud or abuse investigation related to the traditional act of professional courtesy. On the other hand, prosecutions for the routine waiver of Medicare coinsurance have involved schemes to provide medically unnecessary services, and were not examples of professional courtesy."
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

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