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Re: Employee copays

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  • Melinda
    Oh sure...glad I could be of help. The questions that were asked I found awhile back, some Q&A thing, but it still rings true. I already had this typed up
    Message 1 of 8 , Feb 27, 2007
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      Oh sure...glad I could be of help. The questions that were asked I
      found awhile back, some Q&A thing, but it still rings true. I
      already had this typed up from an Office Manager's meeting I had
      attended and I provided this information to them; so I just cut &
      pasted (love that feature!). I'm amazed at how ofen I still hear
      about this though!!!! Sorry the Medicare link didn't work, but they
      recently changed their web site around...Arrgh!

      Melinda Brown,CMBS
      Ins Biller

      --- In MedicalBillers@yahoogroups.com, Michelle Uhl <muhl4groups@...>
      wrote:
      >
      > Great Information Melinda!!!!.. it's very important that we stress
      to our physicians the importance of following the guidelines set
      forth in the regulations and contracts we are given to adhere to..
      >
      > Melinda <melindadocsmith@...> wrote: It is fraudulent and
      a federal & state offense to waiving copayments
      > & deductibles.
      >
      > The Office of Inspector General is the one who follows up and
      > monitors these issues. Their web site is: http://oig.hhs.gov/
      >
      > Question 1: Is there anything wrong with not collecting co-payments
      > and deductibles from my patients?
      > Question 2: Is it legal to discount our fee schedule for Medicare
      > patients who are broke? Can we waive copays?
      > Question 3: I routinely waive copays for patients who have waited a
      > long time to see me or who are in financial distress.
      > Question 4: Can we offer courtesy professional discounts to other
      > physicians?
      > ----------------------------------------------------------
      > 1) Question: Is there anything wrong with not collecting co-
      payments
      > and deductibles from my patients?
      >
      > Answer: The answer is yes, plenty. The routine waiver of co-
      payments
      > and/or deductibles can constitute a violation of the federal anti-
      > kickback statute (42 U.S.C. Section 1320a-7b) as well as applicable
      > state law.
      >
      > The federal anti-kickback statute prohibits the payment of
      > remuneration (which includes the transfer of anything of value) to
      > induce referrals of business for which payment may be made by the
      > Medicare or Medicaid programs. In essence, by routinely waiving co-
      > pays or deductibles, you are encouraging – or inducing – patients
      to
      > come to your practice rather than others – and expecting Medicare
      to
      > cover your generosity.
      >
      > The Health Insurance Portability and Accountability Act of 1996
      > (HIPAA) further provides for civil monetary penalties for offering
      or
      > transferring remuneration to Medicare and Medicaid beneficiaries
      that
      > the physician knows or should know is likely to influence the
      > individual to receive covered services from the physician.
      >
      > The routine waiver of co-payments and deductibles can also
      constitute
      > insurance fraud. (For example, if an insurance company agrees to
      pay
      > a physician 80 percent of his or her usual and customary charges,
      and
      > the physician submits a claim for $100 but routinely waives the $20
      > co-payment, the insurance company could argue that the physician's
      > usual and customary charge is $80 rather than $100. In that event,
      > the insurance company might be responsible for only 80 percent of
      the
      > $80 charge or $64).
      >
      > In general, waivers of co-payments and deductibles are permitted
      only
      > if they are not advertised, not routine, and are granted only to
      > financially needy patients or where a reasonable collection effort
      > has been made. (See below for addt'l info. on this issue).
      > ----------------------------------------------------------
      > 2) Question: Is it legal to discount our fee schedule for Medicare
      > patients who are broke? Can we waive copays for these people?
      >
      > Answer: The Department of Health and Human Services issued a
      > statement allowing discounts and copay waivers for indigent
      patients
      > visiting hospitals, but it does not specifically address physician
      > practices.
      >
      > The OIG does allow occasional copay waivers if physicians have
      tried
      > to collect and patients are experiencing financial hardship. Here
      is
      > its statement:
      > http://oig.hhs.gov/fraud/docs/alertsandbulletins/121994.html
      >
      > "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
      may
      > violate the statutes discussed above and other provisions of the
      law."
      >
      > We never advise providers routiinely to bill "insurance only."
      > Discounts and waivers should happen in limited circumstances and
      > should be applied consistently -- that is, you should treat all
      > patients the same.
      >
      > You may also be interested in the American Medical Asociation's
      > position on copay waivers (this includes deductibles):
      >
      > E-6.12 Forgiveness or Waiver of Insurance Co-payments.
      >
      > Under the terms of many health insurance policies or programs,
      > patients are made more conscious of the cost of their medical care
      > through co-payments. By imposing co-payments for office visits and
      > other medical services, insurers hope to discourage unnecessary
      > health care. In some cases, financial hardship may deter patients
      > from seeking necessary care if they would be responsible for a co-
      > payment for the care. Physicians commonly forgive or waive co-
      > payments to facilitate patient access to needed medical care. When
      a
      > co-payment is a barrier to needed care because of financial
      hardship,
      > physicians should forgive or waive the co-payment.
      >
      > A number of clinics have advertised their willingness to provide
      > detailed medical evaluations and accept the insurer's payment but
      > waive the co-payment for all patients. Cases have been reported in
      > which some of these clinics have conducted excessive and
      unnecessary
      > medical testing while certifying to insurers that the testing is
      > medically necessary. Such fraudulent activity exacerbates the high
      > cost of health care, violates Opinion 2.19, and is unethical.
      >
      > Physicians should be aware that forgiveness or waiver of co-
      payments
      > may violate the policies of some insurers, both public and private;
      > other insurers may permit forgiveness or waiver if they are aware
      of
      > the reasons for the forgiveness or waiver. Routine forgiveness or
      > waiver of co-payments may constitute fraud under state and federal
      > law. Physicians should ensure that their policies on co-payments
      are
      > consistent with applicable law and with the requirements of their
      > agreements with insurers. (II) Issued June 1993.
      > ----------------------------------------------------------
      > 3) Question: I routinely waive copays for patients who have waited
      a
      > long time to see me or who are in financial distress. My
      > administrator tells me this is illegal. Is it?
      >
      > Answer: Probably. In May 1991, the Office of the Inspector General
      > (OIG) of the Department of Health and Human Services issued
      a "fraud
      > alert" concerning waiving co-pays for Medicare patients.
      Essentially,
      > they said that routinely waiving copayments for Medicare
      > beneficiaries, if you are paid on the basis of charges, is
      considered
      > fraud.
      >
      > Here is their exact language:
      >
      > "To help reduce fraud in the Medicare program, the Office of
      > Inspector General is actively investigating health care providers,
      > practitioners and suppliers of health care items and services who
      (1)
      > are paid on the basis of charges and (2) routinely waive (do not
      > bill) Medicare deductible and copayment charges to beneficiaries
      for
      > items and services covered by the Medicare program.
      >
      > This fraud alert is not intended to address the routine waiver of
      > copayments and deductibles by providers, practitioners or suppliers
      > who are paid on the basis of costs or diagnostic related groups.
      The
      > fact that these types of services are not discussed in this fraud
      > alert should not be interpreted to legitimize routine waiver of
      > deductibles and copayments with respect to these payment methods.
      > Also, it does not apply to a waiver of any copayment by a Federally
      > qualified health care center with respect to an individual who
      > qualifies for subsidized services under a provision of the Public
      > Health Service Act."
      >
      > The OIG considers it fraudulent to waive copays because:
      >
      > · You end up "misstating" your actual charge — and forcing
      > Medicare to pay out more than it should. Here's the OIG's
      > example: "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;"
      >
      > · Waiving copays may induce patients to see you rather than
      > other providers. That violates anti-kickback rules; and
      >
      > · HCFA wants Medicare beneficiaries to be good, thoughtful
      > consumers of healthcare. Copays are designed to incentivize
      patients
      > to think twice about coming in for care that may be unnecessary. By
      > waiving copays routinely, you ruin that incentive program — and
      cost
      > Medicare more.
      >
      > Punishment for fraud in this area is serious. According to the
      Civil
      > Monetary Penalties law, you could be liable for up to $10,000 for
      > each service fraudulently billed, $15,000 for each individual whose
      > copay you waived, and $10,000 for each day your "coercive"
      > relationships with a patient continued. You can also be kicked out
      of
      > the state healthcare program.
      >
      > The OIG does understand that there need to be exceptions to the
      copay
      > rules for truly needy people. However, these should be exceptions,
      > not the routine. You'll need to carefully assess each patient's
      > financial hardship, not dismiss copays as a general rule for anyone
      > who complains.
      >
      > You can read the full OIG fraud alert on this subject at
      > www.dhhs.gov/progorg/oig/frdalrt/121994.html.
      >
      > Of course, all this applies only to Medicare. If you waive copays
      for
      > patients in private plans, your legal obligations are spelled out
      in
      > your payer contract. If you have agreed to collect copays in a
      > legally binding contract, you had better collect the copays. In
      > general, waivers are permitted only if they are not advertised, not
      > routine and are granted only after a resonable effort to collect.
      > Check each of your contracts to understand your obligations.
      > ----------------------------------------------------------
      > 4) Question: Can we offer courtesy professional discounts to other
      > physicians?
      >
      > Answer: According to attorney Todd Rodriquez of Philadelphia-based
      > Gosfield & Associates, professional courtesy discounts can raise
      > issues under the federal anti-kickback and false claims statutes,
      > whether the discounts are given under Medicare or with commercial
      > insurances.
      >
      > Certainly, don't give discounts and free services to physicians or
      > others that make or influence referrals to the practice; that makes
      > the service or discount appear could be construed to be kickback.
      In
      > other circumstances, if you do provide courtesy discounts, set a
      > policy to write off the entire charge and not just the copay.
      > Medicare and commercial payers may view the routine waiver of
      copays
      > as a misstatement of the physician's actual charge, resulting in
      > false claims liability.
      >
      > In addition, case law supports commercial payers who may say that
      > since the patient didn't incur any costs, it has no obligation to
      pay
      > for anything since insurance exists to pay for financial risk
      > associated with services. If there is no charge, there is no
      > financial risk to insure.
      >
      > Melinda Brown, CMBS
      > Ins Biller
      >
      > --- In MedicalBillers@yahoogroups.com, Denise <denise64atwork@>
      > wrote:
      > >
      > > Does anyone out there write off copays/deductibles for their
      > employees?
      > >
      > > Thanks
      > > Denise
      > >
      > >
      > > ---------------------------------
      > > Don't pick lemons.
      > > See all the new 2007 cars at Yahoo! Autos.
      > >
      > > [Non-text portions of this message have been removed]
      > >
      >
      >
      >
      >
      >
      >
      > ---------------------------------
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      >
      > [Non-text portions of this message have been removed]
      >
    • J. Scott Gleaton
      Yes. If this is a benefit offered by the physician, most definitely. J. Scott Gleaton 10515 US Hwy 431 LaFayette AL 36862-5421 Telephone: (334) 864-5112 ...
      Message 2 of 8 , Feb 27, 2007
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        Yes. If this is a benefit offered by the physician, most definitely.


        J. Scott Gleaton
        10515 US Hwy 431
        LaFayette AL 36862-5421
        Telephone: (334) 864-5112



        ----- Original Message ----
        From: Denise <denise64atwork@...>
        To: billing@...; crn-l@yahoogroups.com; MedicalBillers@yahoogroups.com
        Sent: Monday, February 26, 2007 11:44:46 AM
        Subject: [MedicalBillers] Employee copays

        Does anyone out there write off copays/deductibles for their employees?

        Thanks
        Denise

        ------------ --------- --------- ---
        Don't pick lemons.
        See all the new 2007 cars at Yahoo! Autos.

        [Non-text portions of this message have been removed]




        [Non-text portions of this message have been removed]
      • Cyndee Weston
        Sorry for the tardy reply on this, I ve been out of the office but I felt compelled to reply. It is improper to waive copays for employees, too! If you file a
        Message 3 of 8 , Mar 8, 2007
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          Sorry for the tardy reply on this, I've been out of the office but I felt
          compelled to reply.



          It is improper to waive copays for employees, too! If you file a claim
          knowing you are not going to collect the copay without giving the insurance
          carrier an equal discount off the top, you are submitting a false claim and
          possibly invoking the anti-kickback statute as well.



          Under HIPAA CMP, it doesn't matter if the insurer is a Government carrier or
          a commercial carrier - it is fraud and it is punishable with monetary
          penalties and even jail time. Regardless of whether you call it professional
          courtesy, voluntary write off OR courtesy for employee, it is fraud.



          No discounts or write offs should be given or applied unless a true,
          documented hardship exists OR you've made a reasonable effort to collect the
          patient's portion and have been unsuccessful. I say this with confidence in
          having spoken directly with the OIG on this very matter. Also, our
          association does have legal General Compliance Counsel on retainer that has
          trained and worked with OIG investigators and Federal Marshals and he is of
          the same opinion. We have discussed this often as it is a topic where there
          are many that are under the wrong impression regarding offering discounts.



          Cyndee Weston

          American Medical Billing Association

          www.ambanet.net/AMBA.htm



          _____

          From: MedicalBillers@yahoogroups.com [mailto:MedicalBillers@yahoogroups.com]
          On Behalf Of Ms. Pinky
          Sent: Tuesday, February 27, 2007 6:21 AM
          To: MedicalBillers@yahoogroups.com
          Subject: Re: [MedicalBillers] Employee copays



          Out of courtesy if the patient is an employee of the practice-- I know that
          many practice offices waive this. If you think about it, its like a small
          benefit that you get from your company.

          Let's say, I work for a Pediatric office. My insurance gets billed for the
          visit, but my practice do not collect copay from me. We don't "WRITE IT
          OFF"---- we say "COURTESY FOR EMPLOYEE".

          It is illegal not to collect deductibles and coinsurances (Anti-Kickback
          Law) if the beneficiary is from a Federal Funded coverage.

          And also, most insurance companies really require the policy holders to pay
          their copays everytime they see their providers in the office.

          But again... if you are an employee of the practice, it is the discretion of
          the company if they will waive your copay or not.

          This is based on my years of experience in this business .


          KERRY SYLVAN <abcmdbiller123_ <mailto:abcmdbiller123_55%40msn.com>
          55@...> wrote:
          DENISE, IT IS AGAINST THE LAW NOT TO CHARGE FOR COPAYS, DEDUCTIBLES OR
          COINSURANCES TO PATIENTS. DON'T KNOW THE LAW CODE, BUT THERE IS A NEWSBRIEFE
          ON IT.
          THINK ABOUT IT THIS WAY,

          IF ONE OFFICE CHARGE AND THE OTHER OFFICE DOES NOT CHARGE WHICH OFFICE WOULD
          THE PATIENT GO TO?
          IT IS IMPROPER TO DO THIS.

          JT BILLER NY

          ----- Original Message -----
          From: Denise<mailto:denise64atwork@ <mailto:denise64atwork%40yahoo.com>
          yahoo.com>
          To: billing@codelist. <mailto:billing%40codelist.net>
          net<mailto:billing@codelist. <mailto:billing%40codelist.net> net> ;
          crn-l@yahoogroups. <mailto:crn-l%40yahoogroups.com>
          com<mailto:crn-l@yahoogroups. <mailto:crn-l%40yahoogroups.com> com> ;
          MedicalBillers@ <mailto:MedicalBillers%40yahoogroups.com>
          yahoogroups.com<mailto:MedicalBillers@
          <mailto:MedicalBillers%40yahoogroups.com> yahoogroups.com>
          Sent: Monday, February 26, 2007 12:44 PM
          Subject: [MedicalBillers] Employee copays

          Does anyone out there write off copays/deductibles for their employees?

          Thanks
          Denise

          ---------------------------------
          Don't pick lemons.
          See all the new 2007 cars at Yahoo! Autos.

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