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Foundations of the Billing and Collections Process

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Your practice finances questions answered

Q: Can I have multiple Time of Service Discounts?

A: The definition of Time of Service (TOS) Discounts: Discounts based on the bookkeeping savings for a patient paying now, rather than being billed later, and usually offered to avoid mailing a statement to the patient and waiting for the payment. It is not reasonable to consider that an office would have multiple TOS discounts.

Q: We are in the process of establishing the proper Hardship Agreement Guidelines for our office. What percentage reduction do we use for 200% of poverty level? The same goes for 300% and 400%. We were thinking 25, 50, 75? Your thoughts, please.

A: On our hardship form, we have increments of 100% of poverty, 133% of poverty (meaning 33% above the guideline), 150%, 175%, and 200%. Patients that would be considered 400% of the poverty level would likely not be eligible for a hardship discount. If you decide to go higher, base your decision on several factors: What is the maximum you want to allow for the "at poverty level" discount? Basically, you're saying that if someone is at the poverty guideline they get X percent off your actual fee. If your actual fee for a New Patient examination 99203 is $150, you might say the 100% level gets an 80% discount or 90% discount - whatever you want. The increments descend after that, ending with your "CHUSA" cash discount amount. Everything depends on the percentage you choose to take off the first level...so if you wanted to do only 50% at the 100% of poverty level, then your increments may be much smaller.

Q: When a patient comes in, how do we know what to collect? How do I make sure they have not already used their visits for the year?

A: One of the most important steps in the patient financial relationship is the verification of any insurance coverage held by the patient. The most accurate up-to-date information is usually obtained over the telephone. You can ask detailed specific questions about the codes that might be billed or about certain benefit limits or visits already used. Based upon the information obtained through this process, you will know the expected amount to be collected from the patient

Q: How do HSA's and flex plans work for maintenance care? I know patients can use them for Active chiropractic care but can they be used for maintenance/wellness care? Should we be billing them a certain way if it is considered maintenance?

A: HSA and HRA accounts are like savings accounts that can be used for any service medically related, like deductibles, copayments, non-covered items, etc. The Internal Revenue Service has more detailed information on its website on exactly what services can be paid for out of an HSA account. Also, just as you would verify insurance benefits, you should verify with the HSA/HRA carrier. Each carrier can have specific guidelines that you need to be aware of.

If the care is for Active Treatment, you would use the Chiropractic Manipulative Treatment codes (98940-98943). If the care is for maintenance or wellness purposes, the HCPCS code S8990 might be more appropriate, but it is always best to check first to see if they recognize the use of this code.

Q: Is it legal if I offer care plans with discounts based on how many visits the patient purchases that may eventually provide the equivalent of a free visit?

A: According to the Office of Inspector General (OIG), care plans that incentivize the patient to purchase more visits are an inducement violation. A modest Time of Service discount of 5-15% (or state limit if different) can be offered to patients for services not covered by insurance that are paid when the services are rendered.

Q: When a patient has maxed out on their insurance benefits, do I keep submitting to insurance companies and just keep getting the denials, or should I sit down with the patient and switch them to cash?

A: If you had completed a verification of benefits when the patient began treating, you would be able to confirm that the patient was, in fact, maxed out on benefits. If you received an EOB that indicated that the patient max has been met, it is recommended that you contact the payor to confirm, as there may have been charges that were overturned. Once you have confirmed that the benefits have maxed out, you will need to have a conversation with patients to inform them that the insurance will no longer pay. Should they continue care, they will be fully responsible for all charges after the maxed out date. Continued billing of the charges depends on two things: the carrier contract and the patient's choice. If your carrier contract states that you must bill for non-covered services, you would need to continue to bill. Also, if the patient has secondary insurance, you would continue to bill in order to receive the necessary denial for the secondary.

After you explain to patients that their benefits are maxed, if they indicate to you that they do not want you to continue to bill the carrier, you should have a form (Notification of Non-Coverage) for the patient to sign, instructing you not to bill the carrier. (This is very similar to the Medicare ABN and some other carriers have their own form)

If the patient instructs you to stop billing the carrier, it would be a great opportunity to present the option of a DMPO such as ChiroHealthUSA that will allow the patient to get discounted services. (Once benefits max, the patient may be underinsured.)
Also, when this occurs, remember to turn off billing within your EHR.

Q: I often threaten patients, who have a past due balance, with collections if they haven’t responded to a bill in several months. Sometimes I can’t even get them to call me back. Actually, I haven't ever sent an account to collections and I am hesitant to do so. I’m not sure what's holding me back. Is all this OK?

A: If you don’t have written policies in place for the collection of past due balances, it may cause you to be hesitant in this area. You first have to decide if you're comfortable sending patients to collections when they don’t keep their end of what is truly a business arrangement: you provide care; they pay for services. Then,, based on your decision, and after thoroughly vetting out a collection agency, write a policy that clearly states how bad debt will be handled in your office, and then stick to it. Most importantly, don't threaten collections unless you intend to go through with it. Important Reminder: make sure your compliance policy is clear about how you manage patient collections.

Q: What's the value of bundling each day's EOBs and saving/filing them by date? When would I reference this information? Is it just for record-keeping compliance?

A: The main reason to know the date is in case you have to go back and reference that EOB later. You can correlate this date to the date the item was posted in your billing software, and then cross-reference it to any deposit slip that matches that date. Should anyone ever have to forensically follow the money, it makes a great paper trail. Some offices choose to copy all EOBs and put them into the patient folder. This is an outdated process and not necessary these days because of the bulk checks that come in. Taking that full daily bundle and scanning it to make an electronic copy makes more sense. Bottom line: there's really no compliance issue, but it is definitely convenient.

Q: Are there different types of family/individual deductible arrangements? I thought that all eligible expenses went toward both the individual deductible and family deductible simultaneously until either one or the other was met and then benefits would be paid?

A: Individual and family deductibles can differ within policy groups. We recommend that you verify the application of deductibles when you verify benefits. There is no reason to have a family deductible listed if the whole family isn’t considered to satisfy the family deductible. Usually, that is a “stop-loss” provision to the plan that cuts down the amount the family will have to pay out of pocket. Regardless of what you expect, always verify both family and individual deductibles to help the patient know what to expect.

Q: I have a patient that was involved in a car accident who doesn't want me to bill her car insurance because she says her rates will go up. Don't I have to bill her car insurance before her medical insurance? Or does it not matter if she hasn't informed her car insurance company?

A: First, it depends on what state you live in. If you live in a “tort” state, where everyone has the option to purchase their own medical coverage (and assuming this is what your patient is talking about), then in most cases, using medical coverage, regardless of fault, will not affect rates. But that should be clarified with the insurance company.

Additionally, we recommend explaining to your patient that Box 10 of Form CMS1500 asks the question, “Is Patient’s Condition Related to an Auto Accident?"" By law, you have to check “Yes,” which means that the health insurance may not be liable and probably will not pay as the primary carrier - and if they do, they may subrogate any monies they pay out. If she still doesn’t want you to file the auto insurance, she needs to pay at the time of service. To not say “Yes” on the CMS 1500 is in direct violation of the False Claims Act.

Q: Am I in compliance if I express appreciation for referrals from my patients by way of a free massage or some other service?

A: The Federal Anti-Kickback Statute is a criminal statute that prohibits the exchange (or offer to exchange) anything of value in an effort to induce or reward the referral of federal heathcare program business. Conviction for a single violation under the Anti-Kickback Statute may result in a fine of up to $25,000 and imprisonment for up to 5 years (See 42 U.S.C. § 1320a7b(b). In addition, conviction results in mandatory exclusion from participation in federal healthcare programs.

Q: I would like to know what we need to do to start charging interest on accounts that are past due?

A: The one general rule with charging interest is that it must be consistent. The amount must be applied to all patients' accounts and the policy/procedure must be clear as to what percentage is applied and specify the age of the accounts when interest begins to accrue. Your office financial policy must also clearly define this so that patients are aware from the beginning that interest is charged for late accounts.
In regards to the percentage, most states don't specify a maximum percentage and instead allow practices to determine what is reasonable and to implement appropriate policy. However, to be sure that your state allows you to select your own percentage or if they have a recommended or maximum amount, you would need to contact your local state association board.

Q: Sometimes we have patients come into the office who ask if we can discount their services because they have a reduced income. The doctor wants to help them. Is this okay?

A: Your office must have a written Financial Hardship policy which outlines how fees are calculated based on patients' ability to pay. You cannot just discount fees based on what patients tell you. You must be able to prove you reviewed their financial statements, such as a tax return or a bank statement, and that you compared that data to your Financial Hardship policy guidelines to determine what discount the patient might be eligible to receive.

Q: When we bill a carrier that we are not contracted with, and the insurance does not allow the full amount of the charge, do we have to balance bill the patient for the difference between what we billed and the allowed amount, or can some of that money be written off if we choose to do so?

A: If you are submitting bills to insurance companies on your patient’s behalf, even though you are non-participating with that carrier, you are not contractually obligated to write off the difference between the total charge and the allowed amount. If you choose not to collect the full fee that you billed and to write off the balance, this could be considered a dual fee schedule which is not compliant.

If you want to discount the fee for the patient, a true Discount Medical Plan Organization like ChiroHealthUSA is the safe way to do that.

Q: If you charge patients the same amount for all services but do not make them pay the full amount, is that legal? In other words, their insurance runs out and you charge them on the books $122.00 but only make them pay $65.00.

A: No, this is considered a dual fee schedule. If you are stating that your fees for these services are $122, then you must account for the patient paying the total $122. The only exceptions to this are any contracted fee schedules you have in place, like In Network Participation with an insurance carrier or enrollment in a Discount Medical Plan Organization like ChiroHealthUSA.

Q: We have a document, not often used, patients can sign to acknowledge that they have insurance, but want to “opt-out” of us billing their insurance for their chiropractic care. Do we need this document, or can we simply move patients’ files to “cash” instead of “insurance” and continue billing them directly?

A: Your best, compliant way to handle this would be to add a DMPO (Discount Medical Plan Organization) like ChiroHealthUSA (www.chirohealthusa.com). They have an attorney that created a letter for the patient to elect to self-pay.

The contract that the doctor signed to receive provider status with the insurance carrier drives what you can and cannot do as far as balance billing to the patient. It usually insists that you bill everything to them. It is your responsibility to know what you agreed to and comply with it.

Q: What is a "Silent PPO"?

A: The term ‘silent PPO’ was coined in the mid-1990s to describe a network that allows access to its health care provider list and their associated reimbursement discounts. “Silent PPO” is the term used to describe when a non-contracted payer or plan administrator applies a contracted payer’s fee schedule to services rendered by a provider, without the provider’s prior knowledge or consent. They actually “rent” networks of preferred providers from payers.

The provider is usually unaware that these silent PPOs have access to the contracted payer fee schedules and the services covered by the plan. Often, the first indicator of a ‘silent PPO’ arrangement is the EOB you receive. The EOB will include language similar to, “discount applied due to contractual allowance with ‘Your Network.’”

Q: My patients often have non-covered services that we charge a discounted price for. We're implementing payment plans, and will no longer be able to offer the “time-of-service” discount. Is there any way to help the patient get a discount?

A: We recommend using a Discount Medical Plan Organization (DMPO). The cost to you is free, and patients can join for just $49 per year, per family in order to receive legal discounts based on your actual fee schedule We highly recommend ChiroHealthUSA.

Q: My patient's account was sent to a collections agency. The patient is now saying we never even billed her after we billed her three times with no response! What can we do?

A: First and foremost, your office should have a Financial Policy and Procedure, in writing, for this process. Next, you should have a signed statement (usually signed at the onset of care with the initial paperwork) that patients sign stating they understand that regardless of insurance coverage (MM, PI, WC, etc.) they are fully responsible for the payment of services rendered. Then, any and all collection efforts of the practice should be documented in the patient’s file with copies of the bill(s), follow-up letters, reports of telephone and personal contact, etc. There should be extensive notes of any payment arrangements that were made and/or defaulted on or any reasons the patient has given you for non-payment. All notes should be date-and time-stamped for accuracy, along with the name of the staff member. If these actions are not documented, you may want to decide if you're willing to eat this one due to lack of information on your part, and then work quickly to get your policy and procedures in order to ensure this doesn’t happen again! DOCUMENT, DOCUMENT, DOCUMENT!

Q: Do you know if there is a legal way to "trade" with a patient (I treat you, you mow my lawn or fix something, etc.....) I know a lot of docs do this but it seems like it would be some kind of Stark violation, possibly an illegal "referral"???

A: If you are going to barter services, it needs to be done dollar for dollar. The ledger should reflect the value of the beautician's services as a payment on the account. You should give the person you are bartering with something to sign and log the credit in her account.

The danger of bartering is with the IRS. You must turn in all of your bartering to your accountant at the end of the year. You will pay taxes as appropriate. This is usually where the trouble lies.

Q: I have a question regarding the destruction of EOB's. How long do I have to keep EOB's?

A: First, it’s important to know that there are no rules around this. This is not considered part of a patient’s medical record that does have rules for how long they must be kept. We suggest that at the end of a day, once all the EOBs are posted for the day, they are scanned in as part of the Daily Bundle. That is housed by date, either in a secure shared folder on a network, or within some other HIPAA compliance resource like certain Dropbox accounts or Share File accounts. Then, you can access the information at any time, by referring to the date posted and finding the corresponding EOB. You may find that many come as ERAs now…or Electronic Remittance Advices, and are already electronic.

The decision to destroy them after posting is yours. Best practice is to keep that information in case you need it. And storing electronically is a wonderful way to do so without the space issues. There is an excellent module in our Library that addresses this.

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I just think your materials are fabulous.  There is a lot of clarity in the printed materials and webinars.  Kathy has a way to cut to the heart of the matter by making it clear by simplification.

Alice K.
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