There are several scenarios in which health care providers deem it appropriate to waive the patient`s insurance liability. Scenarios may include patients who want to be professionally courteous to colleagues or families when patients are experiencing financial hardship and recovery efforts are having negligible results. Each example includes regulatory and legal issues that health care providers must consider. Not all waivers of co-payments and deductibles are illegal per se. In fact, there are certain circumstances in which the government will allow the derogation. Each patient`s case must be considered individually and the waiver must meet the following criteria: While the Centers for Medicare and Medicaid Services (CMS) and the Office of the Inspector General of the Department of Health and Human Services (OIG) are not alarmed by the occasional waiver of co-payment obligations — due to financial hardship or uncollectability — the systematic waiver of co-payment obligations under Medicare. is clear. problematic. So if a provider tells the government that the “actual fee” is $100, Medicare is willing to pay $80. However, if the supplier regularly waives the $20 co-payment, the actual cost is $80.
The provider inflated its actual cost by $20, and if Medicare had known the truth, it would have paid only 80%, or $64. Suppose the practice charges $100 with Medicare – expecting to get $80 reimbursement and then “waives” the $20 co-payment. In this case, he would have scammed Medicare of $16. For example, if a vendor, practitioner or supplier claims that a service fee is $100 but systematically waives the co-payment, the actual fee is $80. Medicare should pay 80% of $80 ($64), not 80% of $100. As the sign at my father`s hardware store stated, “There is no free meal.” Someone has to cover the $16 payment gap, and that`s usually all of us as health care consumers and taxpayers. The Copay waiver occurs whenever a health care provider is paid by an insurer, but chooses not to collect a co-payment. Waiver of quotas can take various forms. It is important to remember that not all Copay exemptions are illegal. Only routine co-payment exemptions designed to create additional cases that break the law. For example, the OIG highlighted its concern about the systematic exemption of co-payments and deductibles in its Compliance Program Guide for Individual and Small Group Practices (65 F.R.
59434), published on October 5, 2000, in which the OIG stated that waiving co-payment obligations for private insured patients can also be problematic. Like CMS and the OIG, private insurers and courts generally do not concern themselves with occasional accommodations for individual patients with documented financial constraints. However, insurance companies have successfully challenged the systematic waiver of co-payment obligations in court on several occasions. It is entirely appropriate for health care providers, physicians or providers to waive the co-payment if the patient has a demonstrated financial need. Similarly, a legitimate patient assistance program (often referred to as a PAP) is completely legal. However, the provider must make an individual determination of the patient`s needs. If a provider regularly waives co-payments due to financial hardship without actually assessing patients` needs, this is against the law. The same laws apply to Medicare, Medicaid and Tricare patients, but the risk is greater if your office doesn`t comply — health care providers can be charged with fraud against a government agency. The waiver of coinsurance raises potential issues with the federal anti-bribery law, the federal false claims law, and liability under state law. In addition, your practice must apply hardship programs to all patients. They can`t waive a patient`s insurance debt for those with statutory health insurance in times of crisis, but they can require private insured patients to pay the full copayments, regardless of their financial situation. Patients are responsible for co-payments and deductibles.
Systematic waiver of coinsurance requirements is illegal because it results in 1) false claims, 2) violations of federal anti-bribery law, and 3) excessive use of items and services paid for by Medicare. Some providers naively forgo co-payments and deductibles in order to be “good guys” and help patients, or to save the cost and effort of continuing funds after service. However, when providers do, they distort the actual costs, increase the cost of health care plans, and increase the burden on taxpayers. In addition, sellers and manufacturers often use Copay waivers to get doctors to prescribe their drugs or products instead of cheaper generic competitors. Anti-bribery law also prohibits offering discounts to encourage prescriptions or recommendations for your product. If your practice has a good reason not to make a co-payment, co-insurance or surplus, or not to pursue debt collection against a patient, records should be kept of all conversations with the patient. They should be able to prove that efforts were made in good faith to comply with the law and make exceptions only for specific reasons. In addition, health care providers should track all payments and note all payments that have been cancelled as evidence that the patient`s insurance liability is not routinely waived. As noted above, a physician who waives co-insurance, copayments, or otherwise applicable deductibles as a general business practice if such waiver would affect the amount the insurer would pay could be guilty of insurance fraud under Section 176.05(2) of the New York Criminal Law and Section 403(c) of the New York Act. Benchmark pay [such as routine waivers of co-payments and deductibles] is illegal because it can distort medical decision-making, cause overuse of services or supplies, increase the cost of federal health programs, and lead to unfair competition by excluding competitors who are unwilling to pay them.