Posts Tagged billing

Help Us Address “Surprise Billing” Issues

Help Us Address “Surprise Billing” Issues

Last week, the U.S. House Energy and Commerce Committee advanced a legislative package (HR 3630) to address the ongoing “Surprise Billing” issues affecting patients and physicians.

While this is not the same bill the Association and other medical societies were supporting, the committee did agree to adopt an amendment establishing an independent dispute resolution (IDR) process for out-of-network (OON) claims of $1,250 or more. Arbitrators leading the process would be permitted to consider things like median contracted in-network rate, provider’s level of training, experience, quality and outcomes, and acuity of care/services rendered.

Although HR 3630 still has flaws, the Association views this as progress from where we were – there was no IDR language in the original bill. Also, with HR 3502 still awaiting a hearing, it appears HR 3630 will most likely become the primary piece of legislation moving forward in the U.S. House.

With this in mind, we have slightly revised the wording of the previous letter to legislators. Still touting HR 3502 as the model we support, these new revisions more broadly address the need for IDR language to be included in whatever bill goes to the floor. Click here to read our letter to our Congressional Delegation in which several other medical specialty societies have also signed.

What can you do? Contact your legislators! We have prepared an email and guidelines in order to make this process as easy as possible for you. Simply click the button below, enter your information, and stand up for a solution that best addresses the needs of patients and physicians.

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Senate Committee Tackles Surprise Billing

Senate Committee Tackles Surprise Billing

The Senate Health Committee finally passed a major health care package, which could bring an end to surprise billing for patients by capping out-of-network charges at a rate already negotiated by insurers. However, the legislation could see more changes before it sees a full Senate vote.

Wednesday, the Senate Health, Education, Labor and Pensions (HELP) Committee debated S. 1895, the Lower Health Care Costs Act, which included provisions related to protecting patients from surprise medical bills. Included in the bill is language that addresses a variety of other issues, including prescription drug pricing, provider network and pricing transparency, mental health and substance abuse parity, and tobacco regulation. The bill was voted out of committee 20-3.

The surprise billing provisions of the bill are problematic because they would tie out-of-network payments to average in-network rates in situations where a patient did not have the opportunity to choose an in-network provision. It also omits the independent payment arbitration process that the Medical Association of the State of Alabama and the AMA and other physician organizations support.

Physician Sen. Cassidy, (R-LA) offered an amendment to require insurers to post information on network adequacy so that patients can find out in advance if their doctor is in network, which was passed unanimously. Committee Chair Alexander also made a commitment to continue working with members of the Cassidy Working group to address physicians’ concerns about the lack of an arbitration model to address payment disputes. Sen. Cassidy also made strong comments against the surprise billing section in the underlying bill, noting that is it skewed heavily in favor of insurance companies. He warned that letting insurance companies set rates will have dire consequence for rural and critical access hospitals that are already closing due to inadequate payments and it will exacerbate health care market consolidation problems. Sens. Hassan, Romney and Murkowski were also outspoken, expressing concerns with the contracted in-network rate benchmark and speaking in favor of including of an independent dispute resolution mechanism.

The HELP committee is hopeful the bill will be considered on the Senate floor by the end of July. We will continue working with the principals involved to try and get our concerns with the legislation addressed through the amendment process.

Separately, Congressman Ruiz, MD (D-CA) and a significant number of co-sponsors from both sides of the aisle introduced surprise billing legislation Thursday in the House that is based on the New York model.  This is the bill that most physician groups including the Medical Association and the AMA have been waiting to support. This bill includes an independent dispute resolution process with benchmark rates tied to charges.

The Medical Association will continue to monitor developments on the surprise billing legislation and will keep the membership apprised.

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Trump Executive Order Seeks to Put Patients First

Trump Executive Order Seeks to Put Patients First

With high health care costs now a rare bipartisan issue and lawmakers on both sides of the aisle demanding action, President Trump issued an executive order on June 25 to increase transparency in hospital prices, physician fees and other health care providers to disclose more information about their billing and pricing.

Read the Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First and the White House Fact Sheet

The purpose of the order, entitled “Improving Price and Quality Transparency in American Healthcare to Put Patients First,” is to direct federal agencies to issue regulations to improve the transparency of health care prices and quality in order to create a more competitive marketplace and provide consumers with the information they need to make informed purchasing decisions.

More specifically, the executive order:

  • Directs the Secretary of Health and Human Services (HHS) to issue regulations within 60 days that would require hospitals to publicly post standard charge information, including information based on negotiated rates, in an easy-to-understand format.
  • Requires the Secretaries of HHS, Treasury, and Labor to issue an advance notice of proposed rulemaking within 90 days seeking comment on proposals to require health care providers, insurers, and self-insured group plans to provide consumer access to information about expected out-of-pocket costs before they receive health care services.
  • Requires the Secretary of HHS, in consultation with the Attorney General and the Federal Trade Commission, to issue a report within 180 days on ways the federal government or private sector impede health care price and quality transparency for patients, with recommended solutions.
  • Directs the Secretary of HHS, within 180 days and in consultation with other federal departments and agencies, to increase access to de-identified claims data from taxpayer-funded health care programs and group health plans for researchers, innovators, providers, and entrepreneurs to facilitate the development of tools that empower patients to be better informed purchasers of care.
  • Requires the Secretary of the Treasury, within 180 days, to propose regulations to treat expenses related to certain types of arrangements, potentially including direct primary care and health care sharing ministries, as eligible medical expenses for Health Care Savings Accounts, and to increase the amount of funds in flexible spending accounts that can carry over at the end of the year without penalty.
  • Directs the Secretary of HHS to submit a report to the President within 180 days on additional administrative steps that can be taken to address the issue of surprise medical bills.

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Don’t Get Caught in a Copay Conundrum

Don’t Get Caught in a Copay Conundrum

In the current environment of increasing patient deductibles and copays, the billing and collection of the patient portion of the services you provide is top of mind. In the Department of Health and Human Service’s report dated May 23, 2017, Alabama’s average monthly health insurance premium amounts increased 223 percent from 2013 to 2017, versus the national average increase of 105 percent. In real dollars, average monthly premiums jumped from $178 to $575.

With deductibles and copay amounts increasing as well, it’s becoming more difficult to collect the patient’s portion of the bill. As a provider, you are more than aware of these financial hardships your patients are facing, especially your sicker patients who absolutely need care. You might routinely waive the patient portion of your services because you sense a financial issue. Maybe you treat other physicians or colleagues and write off their portion of the bill as a professional courtesy. You might even provide care to your team of employees at a reduced rate as a perk of their job. But did you know all three of these scenarios can land you in hot water?

These practices, while intended to be a gesture of goodwill, professional courtesy, or “it’s just the way we’ve always done things,” could put you and your practice at risk of violating federal anti-kickback statutes and violating contracts with insurance carriers – not to mention impacting your practice’s financial bottom line.

According to the Office of Inspector General, the federal Anti-Kickback Statute (AKS) is “a criminal law that prohibits the knowing and willful payment of ‘remuneration’ to induce or reward patient referrals or the generation of business involving any item or service payable by the federal health care programs.” Violating the federal Anti-Kickback Statute can lead to criminal penalties and administrative sanctions. The penalties for physicians who pay or accept kickbacks can be up to $50,000 per kickback plus three times the amount of the remuneration in question as well as imprisonment and exclusion from future participation in federal health care programs. The HHS’s A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud & Abuse states the following:

“…Where the Medicare and Medicaid programs require patients to pay copays for services, you are generally required to collect that money from your patients. Routinely waiving these copays could implicate the AKS, and you may not advertise that you will forgive copayments.” In this case, the HHS would determine a practice is violating the AKS if their standard practice is to waive copays. Patients would become the referral source and would be receiving the benefit of a waived copay.

From a commercial insurance carrier’s point of view, if you routinely write off patient’s copays and deductibles, you are in essence decreasing the total charge for the service you are providing. A $100 visit with a $20 copay that is routinely waived has now become an $80 visit.

Commercial insurance carriers can view this as a breach of contract, and they have recently been cracking down on enforcement of collections. Commercial carriers can stipulate that copay portion is required to be paid in order to reimburse the practice its portion. If they find out you have been waiving the patient portion for services, they can come back and seek repayment of funds they’ve already paid for those patients.

Profit margins for services are getting smaller and smaller, and as a medical practice in today’s post-ACA world, your bottom line can’t afford the consistent waiver, or poor collection of these copays and deductibles.

To navigate this issue, we recommend you review/update or implement policies and procedures guided by these best practices:

  1. Immediately stop any current practices of routinely waiving or reducing copays and deductibles.
  2. Where financial need is an issue, develop a policy with outlined procedures to document a patient’s financial hardship. Having a patient merely sign a document stating they have a financial hardship is not enough to substantiate the patient’s inability to pay. Have a designated staff person/financial counselor document the patient’s financial need. You need to perform due diligence with the patient to prove they are unable to pay. The HHS’s Roadmap for New Physicians states, “… you are free to waive a copayment if you make an individual determination that the patient cannot afford to pay or if your reasonable collection efforts fail.” Train front desk and billing staff on these policies and procedures to ensure consistent enforcement.
  3. Bill copays and deductibles and make adequate attempts to collect from the patient. We recommend at least three statements and a phone call as a best practice. Document all communication and collection efforts in the patient’s file to provide an adequate audit trail, should you need such information in the case of an audit.
  4. If these three practices bear no fruit, you can write off the patient’s copay or deductible.

As you can see, justifiable circumstances of financial hardship or need are situations where you can discount or waive patient copays. Use these best practices to implement consistent and reasonable policies and procedures. Steer clear of routine waivers and discounts of copays, and you shouldn’t find yourself in a copay conundrum.

The Do’s and Don’ts of Deductibles and Copays

What you should do…

  • Always bill the full amount.
  • Make a reasonable effort to collect from the patient.
  • When a patient states an inability to pay, establish policies and procedures to determine financial need and keep adequate documentation.
  • Work out a payment plan with a patient, or agreement for paying a certain amount each visit.
  • Collect up front rather than later. Each statement sent costs you time and money.

What you should not do…

  • Routinely or systematically write off copays or deductibles.
  • Advertise that you will forgive copays.
  • Accept the “in-network” copays if you are an “out-of-network” provider.
  • Devalue your services by waiving or reducing the copay and deductibles due.

The information in this article is not intended as tax or legal advice. Please contact your lawyer or CPA for specific information regarding your individual situation.

Article contributed by Jenna Roton, CPA, with Jackson Thornton CPAs and Consultants, an official partner with the Medical Association.

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