Transcript Slide 1

Little Things You Can Do And Can’t Do
They add to your income, protect your income and
practice
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 nonaction of other physicians.
Copyright protected. Misuse is subject to prosecution
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Robert E. Goff
Identifying Patients and guaranteeing payments
Collecting Social Security Numbers
Declining to pay to be paid
Holding medical records as hostage for unpaid bills
Opt-out of a service
Who can bill for services provided
Waiving Copays
Escheatment
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Yes You Can Require A Photo ID
 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.
Robert E. Goff
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Fraudulent Use of ID Cards
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 176.05
A 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
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You are at risk for more and more as
patient responsibilities increase
 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
Robert E. Goff
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Yes You Can Require A Credit Card
 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?
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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
Credit Card Acceptance by Physicians
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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
17%
Yes
83%
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No
 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
Robert E. Goff
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50% of overall patient responsibility
goes uncollected
40
35
30
Bills least likely to be paid when
money is tight
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20
15
10
5
0
2007
2008
Non-Covered Benefits
Traditionally provided as a courtesy,. Can you continue to these practices

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.
Robert E. Goff
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 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
Robert E. Goff
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You pay to get paid
Yes You Can Require a Patient to Provide a Social Security
Number
New York State Social Security Protection Law
Effective 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.
Robert E. Goff
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No You Can’t – Hold Medical Records Hostage For An
Outstanding Balance
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
Robert E. Goff

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 – 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, coinsurance, and deductibles established
by the plan.

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?
Contract language obligates the
physician to limit their collection from
patients to contractually established
patient financial responsibility, co-pays,
deductibles, and co-insurance.
Then don’t provide that service.
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
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.
No You Can Not – Bill For Another Physician’s
Services
 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’t – Waive Co-pays
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 -0Robert E. Goff
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How A Professional Courtesy Becomes A False Claim
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)
Robert E. Goff
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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.
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WAIVING CO-PAYS/“INSURANCE ONLY”
MAY EQUAL FRAUD.
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 97-4
1.1.3
Federal Register Vol. 66, No. 33, February 16, 2001, pp.10695-10697
1.1.4
42 CFR section 1001.952(k)
1.1.5
HIPAA, section 231(h), section 1128A
1.1.6
42 U.S.C. 1320a-7(a)(5)
1.1.7
Civil False Claims Act
1.1.8
BBA, section 4331
1.1.9
False Claims Act
1.1.10 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 (7th Cir. 1991)
1.1.12 Managed Care Contracts
1.1.13 State Medical Board Regulations for physicians
Fraud 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.
Robert E. Goff
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BEFORE GRANTING – ASK
 The 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.
Robert E. Goff
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Out-Of Network Being Targeted
 Higher premiums to continue OON
 Mandatory reporting to NYS AG suspicion of
patient portion write-off’s (Insurance fraud)
Robert E. Goff
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Ever wonder what happens to checks that
are not cashed or not delivered?
More Money on the Margin
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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Found
Money!
Nice to find,
but how did
the office
write-off these
funds?
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Robert E.
Goff
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Robert E.
Goff
OUTSTANDING UN-CASHED CHECKS
4-20-11
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
 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?
Robert E. Goff
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