In today’s healthcare environment, providers and their office staff are faced with the daunting challenge of reframing business practice to help maximize reimbursement from not only health insurers but from patients as well. Continuously rising healthcare costs and the growth of high deductible health plans in recent years have plagued patients, providers, payors, and the healthcare system alike. Among a myriad of attempts to tackle the challenges associated with these trends is a federal government and commercial payor crackdown on non-compliance, particularly with medical billing and the associated handling of patient responsibility.
The Office of Inspector General (OIG) under the Department of Health and Human Services (DHHS) issues, as part of the Federal Register, compliance guidance for individual and small group physician practices, hospitals, pharmaceutical manufacturers, and third-party billing companies, among others. Regardless of the setting, and certainly in ambulatory surgery centers (ASCs), there are compliance risk areas identified that all healthcare providers should be aware of. The OIG identified the following specific risk areas related to medical billing: billing for services or items that have not been documented; duplicate billing; unbundling; upcoding; inappropriate balance billing; inadequate resolution of overpayments; lack of integrity of computer systems; failure to properly use modifiers; routine waiver of co-payments; and improper discounts on professional services. We will take a closer look at two identified compliance risk areas in more details- routine waiver of co-pays/deductibles and discounts/ professional courtesy.
Routine Waiver of Co-Pays/Deductibles
Gone are the days when most patients had small co-payments and manageable deductibles that placed little to no burden on themselves or their healthcare providers. In the post Affordable Care Act era, high deductible health plans are on the rise and collecting patient responsibility ushered itself to the top of the priority list for healthcare providers. In 2017, a TransUnion Healthcare analysis reported that 68% of consumers were unable to pay their financial responsibility after services were provided and they expect the percentage of patients not paying their medical bills in full to rise to 95% by the year 2020. This same report uncovered that patient responsibility or patient out-of-pocket expenses (co-pays/deductibles) rose on average 11% in that same year; a trend that does not appear to be slowing. Providers not participating with Medicare and those who are out-of-network are also encouraged to improve proper collection of patient responsibility as a result.
OIG compliance guidance offers that providers should make a good faith effort to collect patient co-pays, deductibles, and patient responsibility from both federally insured (Medicare/ Medicaid/Self-Funded) and privately insured patients. The Centers for Medicare and Medicaid Services offers the following guidance on what constitutes a good faith or reasonable collection effort:
310. Reasonable Collection Effort
To be considered a reasonable collection effort, a provider’s effort to collect Medicare deductible and co-insurance amounts must be similar to the effort the provider puts forth to collect comparable amounts from non-Medicare patients. It must involve the issuance of a bill on or shortly after discharge or death of the beneficiary to the party responsible for the patient’s personal financial obligations. It also includes other actions such as subsequent billings, collection letters and telephone calls or personal contacts with this party which constitute a genuine, rather than a token, collection effort. The provider’s collection effort may include using or threatening to use court action to obtain payment. (See §312 for indigent or medically indigent patients.)
Many commercial insurance carriers have adopted Medicare policy and or have similar guidance regarding attempt to collect. This same reasonable collection effort should be exhausted prior to writing- off patient balances. According to the OIG, the act of billing insurance only or writing-off patient balances without an attempt to collect may violate many regulations including the anti-kickback statute, the false claims act, the civil monetary penalties law, and some state laws.
ASCs can support compliance through concerted efforts to collect patient responsibility at time of service. Today, there are many software programs that help to expedite and streamline this process for both the patient and the facility. Patients are increasingly becoming educated consumers and will benefit from clear information regarding their out-ofpocket expenses particularly when received prior to care being provided. ASCs also have an opportunity to adopt or refine their small balance write-off policy. This policy should be applied consistently to all accounts and should outline qualifications for small debt accounts; typically, when it becomes cost prohibitive to continue an attempt to collect on the balance due and specify the documentation requirements for collection attempts prior to a bad debt write-off. Facilities should also have clearly defined medical and financial indigency policies and economic hardship policies. These policies will bolster the facilities compliance with federal and state guidelines while isolating accounts where patient responsibility is handled differently due to confirmed hardships.
As healthcare providers, we have all experienced real-life scenarios or encountered policies that allow for professional courtesy and patient discounts to healthcare costs. According to the OIG, discounts and professional courtesy may not be appropriate unless the total fee is discounted or reduced. This means that the payor (Medicare or private payor) should receive its proportional share of the discount or reduction that was offered to the patient. Offering the discount to the patient only, while still collecting allowed reimbursement from the insurance carrier, can be viewed as a mis-statement of actual charges and may be a fraudulent practice. The compliance guidance continues by identifying that best practice is to stay away from providing any form of professional courtesy or discount.
Prompt pay discounts are sometimes used to encourage patients to pay most of their outstanding medical bill during a specified period. These programs, though potentially supportive of improved patient responsibility collections, must be structured appropriately to ensure that they do not violate applicable laws and even payor contracts. The federal fraud and abuse laws mentioned above apply to this practice as well and should be reviewed thoroughly and preferably with legal counsel to prevent non-compliance. ASCs must also monitor state statutes that may prohibit the discounting or routine waiver of patient responsibility.
In closing, high deductible health plans have catapulted patients into being one of the main payors in healthcare today. As a result, and in combination with the growing federal and commercial payor focus on compliance, much attention is being given to patient responsibility collection practices. The Office of Inspector General’s compliance guidance lays the footprint for an ASC’s expansive compliance program. New technologies can offer support to business operations through the education of patients and streamlined process improvement of patient collections. Adherence to compliance standards is imperative to the health and prosperity of any facility. In the words of Paul McNulty, Former U.S. Deputy Attorney General, “If you think compliance is expensive, try non-compliance.”
By Kylie Kaczor MSN-RN, CASC, CMPE, CPHRM, ACHE, CPCO, CLSSBB, Vice President, Clinical and Regulatory Affairs, National Medical Billing Service
This post was first published July 8, 2019 and was updated July 1, 2022.