Little Things You Can Do And Can’t DoThey add to your income, protect your income and

practice

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Presented by: Robert E. Goff Official Disclaimers

The information presented is for general information only and are not meant to

substitute for legal advice. Always seek the advice of an attorney on legal matters.

The presenter makes no recommendation as to an individual physician’s participation or non-participation with any specific health plans,

insurance company or payer. Each physician is urged to give due and proper consideration to

their own individual practice needs and act independently regardless of the actions or non-

action of other physicians.

Copyright protected. Misuse is subject to prosecution

1. Identifying Patients and guaranteeing payments2. Collecting Social Security Numbers3. Declining to pay to be paid4. Holding medical records as hostage for unpaid

bills5. Opt-out of a service6. Who can bill for services provided7. Waiving Copays8. Escheatment

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Yes You Can Require A Photo ID

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We have so many patients trying to commit fraud, that is why we get a picture ID. Driver’s License if they have it. We have illegal aliens who use each other’s insurance, IDs, names, and medical histories.

We have had patient’s use their sister’s insurance card, it is doubtful that the same patient was delivered twice in a 6 month period.

Now they are using their kids insurance card for their relatives kids.

Dear Patient:Your insurer has advised this office that the insurance identification card that you presented

as evidence of coverage was not in effect at the time you presented it to this office. Your representation of such insurance was according to your insurer, inaccurate.

Specifically Name of Plan alleges that you your use of their identification card was a misrepresentation, therefore, you are responsible for these charges.

We are not in a position to dispute Name of Plan’s allegation of your misuse of their insurance identification card.

Be advised of New York State law: NY Penal Code Section 176.05A fraudulent health care insurance act is committed by any person who, knowingly and with

intent to defraud, presents, … a claim for payment, services or other benefit pursuant to such policy, contract or plan, which he knows to: (a) contain materially false information concerning any material fact thereto; or (b) conceal, for the purpose of misleading, information concerning any fact material thereto . . .

The presentation of false information as to your insurance coverage could be construed as a fraudulent act the New York State Insurance Department, Fraud Bureau, in accordance with the above.

Such acts are also subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each violation.

Therefore, should you not make payment of this claim in full to this office within the next 15 days, the attached Suspected fraud Report will be forwarded to the New York State Insurance Department, Fraud Bureau.

Questions regarding Name of Plan’s allegation of your misuse of their insurance identification card should be made to Name of Plan at the phone number on the back of your Name of Plan identification card.

Sincerely,Enclosure – Fraud Reporting Form 4

Fraudulent Use of ID Cards

75% of physicians report increase in patient responsibilities

50% of physicians report not knowing the patient responsibility at time of visit

60% of commercial policies now carry a patient deductible of over $100o

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You are at risk for more and more as patient responsibilities

increase

Make a decision about credit cards. Having the ability to accept credit cards for copays and deductibles solves a good number of problems, from not having cash for change (or office pilferages) and most people carry cards, solving the issue, of “I don’t have enough cash for the $10 copay and the cab fare”.

Avoiding Risk If in doubt about a plan’s coverage of a patient, if you can not verify

benefits, insist on obtaining from the patient, before services are rendered, a credit card number and authorization to bill the credit card if the insurance does not provide coverage. The worst that can happen is that you issue a credit to the charge. Most

importantly, you are not chasing patients who have no benefits, expired coverage, or other obstacles to you getting paid.

Plan weasel words – If you look at any eligibility confirmations, you will find that eligibility and benefit confirmations are not guarantees of coverage or benefits – if the payor won’t guarantee, why should you be at risk?

Yes You Can Require A Credit Card

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Survey: Half of Healthcare Providers Do Not Know What Patients Owe at Time of Care, 30 Percent Lose Revenue Due to Uncollected Payments

83%

17%

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Credit Card Acceptance by Physicians

Yes No

NaviNet Survey Shows Nearly 1 in 5 Providers Do Not Accept Credit and Debit Cards, Citing High Processing Fees, Concerns about Financial Regulations as Top Reasons

You do have the right to require contingent credit card authorization

80% of self-pay accounts are never paid in full

50% of patient financial responsibilities become bad debts

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50% of overall patient responsibility goes uncollected

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Bills least likely to be paid when money is tight

Plans and patients try to obtain services from you that are not covered by their health benefit plan. You can choose to stop providing these services as a courtesy and require extra payments from the patient. Telephone consultations Email communications Forms completion

Family Medical Leave Forms Medical Disability Forms Wavier of insurance Forms Waivers for Handicapped Plates Automotive Forms Life Insurance Premium Forms Travel Insurance Forms

Medical record copying Lost prescriptions Refills requested without an apportionment No show fees Re-billing fees

You can implement these fees on a pay source basis

This practice is endorsed by the American Medical Association.

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Non-Covered BenefitsTraditionally provided as a courtesy,. Can you continue to these

practices

You are at risk for copays, deductibles, non-covered services and inaccurate eligibility and benefit representations

You should and can decline to put yourself at risk

Declining to pay to be paid

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You pay to get paid

New York State Social Security Protection LawEffective January 1, 2008 all employers in NYS must take actions designed to help protect individuals against

identity theft. 

This law DOES NOT PROHIBIT the use of Social Security Number (SSN) for legitimate business purposes, however the law does restrict the use and communication of SSNs by businesses, including physician practice.

This means you can require a SSN from your patients, provided that you restrict access to SSNs to the employees that need to see it in registration and billing. Additionally that you secure this information in your practice so that it is not readily accessed by patients, or employees who do not need access. (i.e.: clinical staff)

 The law does prohibit: Intentionally communicating an individual’s SSN to the public; Printing an individual’s SSN on any card or tag required to access products, service or benefits Requiring an individual to transmit their SSN over the internet unless the connection is secure or the SSN is encrypted; Requiring the use of an individual’s SSN to access an internet web site, unless an additional password, identification number or

other authentication device is also used,; and Printing and mailing an individual’s SSN except when required by federal or state law, or except when contained in certain

permitted business documents. If permitted, the SSN cannot be printed on postcards, and must be in a sealed envelope. The Law also requires that reasonable measures are taken to ensure that no employee or staff has access to a SSN for any purpose

other than one related to the conduct of business and to protect the confidentiality of the numbers a practice maintains.

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Yes You Can Require a Patient to Provide a Social Security Number

 A patient owes our practice a large balance, and is well aware of it, but instead of paying, the patient wants to transfer her records to another physician. We are going to refuse to transfer the records, or even give her copies until the balance is paid. It’s ok to hold a patients chart as hostage for unpaid bills.

WRONG

Sorry, you can’t hold the patient’s medical records hostage for unpaid bills. The patient has a right to the records to continue treatment. On a regulatory basis, the patient’s medical care trumps your economic issues.

  You got yourself into this situation by allowing a balance to build up

and become sizable. The lesion is to do what you can to collect on bills during the course of treatment and services, or curtail those services (non-emergent) when payment is not forthcoming.

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No You Can’t – Hold Medical Records Hostage For An Outstanding Balance

No You Can’t – Opt-out of a particular service and charge the patient Don’t like the reimbursement from a plan for a particular service that

you usually provide? Just charge the patient right? 

Wrong.

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A physician’s decision to participate with a health plan is an individual choice, but once that decision is made, with it comes obligations. Leaving aside dealing with the obligatory billing and authorization requirements the most direct and what should be the most obvious obligation is to provide covered services consistent with the physician’s skill, specialty, and range of usual and customary services to a plan enrollee with the economic exchange limited to the co-pays, co-insurance, and deductibles established by the plan.

 Contract language obligates the physician to limit their collection from patients to contractually established patient financial responsibility, co-pays, deductibles, and co-insurance.

But what if a plan is reimbursing a service or a procedure less than it costs the physician to provide? Such is not a happy situation for the physician.

  But what if you believe that the service should be

reimbursed higher and you just don’t want to provide it for less than your costs?

Then don’t provide that service.

Decline to provide a service, directing the patient back to their primary care physician, or referring them to another physician that will provide the service.

What about making the patient sign a waiver that they will voluntarily accept responsibility for the higher cost, and pay for it themselves?

You remain in breach of your contract and remember the patient will claim that they signed the waiver under duress (after all they did not understand and you were demanding they sign to obtain medical care) and regardless of what they promise you, like not submitting the claim to their carrier, they will. And you have opened up a can of worms for little in return.

Even if you “sign the chart”

The treating physician must be the one billing for their services. It is not acceptable for another physician to submit a bill to the patient or the insurance company for someone else’s work Exception – If the treating physician is a resident or fellow

in an academic situation and the supervising physician signs the chart.

This DOES NOT apply to a private practice.

No You Can Not – Bill For Another Physician’s Services

Professional Courtesy is dangerous

Danger in waiving co-pays If you waive the co-pay is it an “inducement” to obtain

services or a reward (if it is another physician) for referrals? Danger in waiving the coinsurance

If you waive the coinsurance File a false claim

Danger in “accepting only what the insurance pays” – in addition to filing a false claim. What if the patient has a deductible? You could end up

with -0-

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No You Can’t – Waive Co-pays

If you submit a bill for services totaling $200 to payer, receive 80% of that amount ($160) and write off the balance ($40) as a professional courtesy, the payer has grounds to argue that the actual fee was only $160 since that is all that the patient is being held liable. Under this circumstance, the payer argues that it should owe only $128 (80% of the actual patient-liable fee of $160)

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How A Professional Courtesy Becomes A False Claim

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Contractual Impediments to Professional Courtesy Waivers

Physicians are generally contractually prohibited from waiving a copayment or deductible under health plan participation agreements.

Most managed care contracts contain clauses precluding a provider from waiving copayments or deductibles. Any violation of the contract by the physician could result in relieving the insurance carrier’s duty to pay a claim.

In 1991, CIGNA argued to the Seventh Circuit that because the plaintiff chiropractor waived the 20-percent copay, he triggered a contract provision which stated that “no payment will be made for expenses incurred . . . for charges which the Employee or Dependent is not legally required to pay.” By waiving the copayment, the provider removed the patient’s entire liability. The Court held that in light of this provision, waiver of a copayment also waived CIGNA’s obligation to pay the provider. By waiving a copayment or deductible, a physician also interferes with the contract between the insured and the insurer.

Take a look at Stark and anti-kick back, the False Claims Acts and state laws, and look at HIPAA 42FR 1320 a – 7b, take a look at: 1.1.1        OIG Special Fraud Alert (1994)1.1.2        OIG Advisory Opinion 97-41.1.3        Federal Register Vol. 66, No. 33, February 16, 2001, pp.10695-106971.1.4        42 CFR section 1001.952(k)1.1.5        HIPAA, section 231(h), section 1128A1.1.6        42 U.S.C. 1320a-7(a)(5)1.1.7        Civil False Claims Act1.1.8        BBA, section 43311.1.9        False Claims Act1.1.10    Public Law 104-191, Subtitle E, Section 242(a)1.1.11    Kennedy v Connecticut General Life Ins. Co  (Case Law) 924 F.2d 698 (7 th Cir. 1991)1.1.12    Managed Care Contracts1.1.13    State Medical Board Regulations for physiciansFraud Aspect of Professional Courtesy• Routine waiver of co-payment issue can be construed as a fraudulent misrepresentation of physician charges.• Insurance consideration– Most insurance companies have “most favored” status in contract, which guarantees lowest prices. This type of payment

modification reduces cost of service, but does not provide discount to insurance company.• Medicare consideration– Under traditional Medicare, physicians are paid 80% of the allowable amount: the lower of the payment schedule amount or

actual charge.

 

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WAIVING CO-PAYS/“INSURANCE ONLY” MAY EQUAL FRAUD.

BEFORE GRANTING – ASKThe AMA advises that physicians should be aware that forgiveness or waiver of copayments 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 copayments may constitute fraud under state and federal law. Physicians should ensure that their policies on copayments are consistent with applicable law and with the requirements of their agreements with insurers.

The approach of Dr. DE, He often treats colleagues and asks them how the colleague manages treating fellow physicians. If a doctor treats his\her patients without charging them, then he would offer his services for free. If a colleague charged their fellow colleagues a full fee, then he would charge his full hourly fee. If the doctors discounted their services, he would discount his service by a similar percentage.

“Treat” others as you would like to be treated. This approach was very tactful, very practical and certainly very fair.

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Higher premiums to continue OON Mandatory reporting to NYS AG suspicion of

patient portion write-off’s (Insurance fraud)

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Out-Of Network Being Targeted

Ever wonder what happens to checks that are not cashed or not

delivered?

The Joanna J Technique Annually go to the NYS Office of the Comptroller,

Unclaimed Funds web site www.osc.state.ny.us

Give them the social security number of the physicians, and the Tax ID. Ask them to search to un-cashed checks, refunds, or other funds they may have that have been turned over to the State as abandoned property.

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More Money on the MarginMore Money on the Margin

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Found Money!

Nice to find, but how did the office write-off these funds?

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New York State NY City

United                    

50,242 5,767

Empire BC/BS 88,082 26,159

GHI 89,312 12,661

Aetna 29,479 8,612

OUTSTANDING UN-CASHED CHECKS4-20-11

What important lesson can be learned from found money?

Recovering money from escheatment means a failure in your accounts receivable management How did this money get by your practice? Who wrote it off? What happened that these funds were lost?

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