Balance Billing...

[KathyG]

I'm looking for some help in gaining a better understanding of "balance billing."  I fully understand that if a provider has a contract with an insurance carrier that they must accept the agree upon amount and can't bill the patient for anything other than their copay and/or coinsurance, if applicable.

One question I have is in the case where a patient has a really high deductible, which in some cases is impossible for them to reach in a year.  For example, a deductible of $5,000.  Is there any way the provider can "cut the patient some kind of break" without it being considered a "kickback?  From what I've read, these laws are written for the benefit of the insurance companies, and have no concern for the patients involved.  It's really sickening.  If a provider is compassionate, they seem to be barred from helping people on a regular basis, unless they fall under what's considered "poverty level."  Am I correct?  Also, under the "Anti-Kickback" laws, it appears that a provider can't even waive or adjust a fee for the "working poor," or those who may not have insurance coverage, could afford to pay a reduced amount, but not the full fee amount.  On the other hand it's okay for the insurance company to negotiate a reduced rate with the provider!  Any input would be appreciated, especially since the new laws are targeting billers now, not just the providers.   

Thanks!

Kathy G. 

[PMRNC]

One question I have is in the case where a patient has a really high deductible, which in some cases is impossible for them to reach in a year.  For example, a deductible of $5,000.  Is there any way the provider can "cut the patient some kind of break" without it being considered a "kickback? 

Easy way to explain this is to simply state how the law is written:  It is illegal to ROUTINELY waive patient OOP ....  That said, it's not to say the doctor can not waive or discount when hardship guidelines are followed (by practice, in the practice financial policy) HE just cannot do this "routinely".   

From what I've read, these laws are written for the benefit of the insurance companies, and have no concern for the patients involved. 

That's not true at all.  Think about this. Patient has a policy to which they have agreed to "cost sharing" their cost sharing is their copay/coinsurance/deductible.   If you charge $800 to which the insurance pays $640.00 and patient is responsible for $160  that $160 is Out of pocket for the insured..but it is also applied to the patient's Out of Pocket Max (stop-loss). MOST plans like this (indemnity plans) will then go to 100% after the stop-loss is met (coinsurance). So if the doctor is WAIVING that $160, the patient and provider have violated the terms of that patient's policy. Why should the carrier apply that stop loss to their out of pocket max when the patient is NOT paying it.   Most people don't think of this, this is why I always think it's a good idea for medical billers to completely understand health insurance. 

Also, under the "Anti-Kickback" laws, it appears that a provider can't even waive or adjust a fee for the "working poor," or those who may not have insurance coverage, could afford to pay a reduced amount, but not the full fee amount.

 

Again, not true.  Again, as law states it cannot be done "routinely".  To avoid having to pick/choose which is wrong on many levels, providers should have a clear and concise financial policy which outlines what they consider to be hardship. If that patient meets the guidelines set forth by the provider for financial hardship, they sign an agreement and it's documented in the patient's file.  Perfectly legal.   This is VERY fair IMHO because it lets the doctor OFF the hook for having to pick/choose who, what and how much to "waive" or discount.  That's fair for everyone.   Why is it fair to TWIP (Take what insurance pays), discount the patient but not the insurance company? It's not. Nor is it legal.   IF there is no financial hardship, you may "discount" but you have to apply (show) the discount to the insurance carrier as well.

Whenever I get a new client, one of the first things I request from them is a copy of their financial hardship guidelines along with office policy, and compliance guides. If they don't have this.. there's a problem. Questions like this one should FIRST be found in those polices of your client .. if you can't find them there, there's a problem.   This also gives you a chance to make some extra cash in helping the provider setup these polices and procedures.

[DMK]

I always appreciate Linda's concise response to the legalities of insurance!  To the biller:  one of the things you need to get yourself behind is that the doctor gets to bill whatever he/she wants only to a point.  And that point is set by the insurance companies and the cost of doing business.  Right or wrong.

If the patient had 100% coverage there would be no questions.  If the patient has a $5000 deductible (I myself have a $4100 deductible) that's what they have.  I'm a Blue Cross insured.  My doctor may bill $200 for a visit, he has agreed to take the (example) $120 that is allowed.  So he already ate (wrote off) $80 of his charge.  Why should I NOT have to pay the $120?  I got a discount, the doctor ate a portion, the only entity that made money for nothing (and they have a contract, processed the e.o.b., so they did at least something) was the insurance company, and I bought their policy so I agreed to it.

I guess what I'm saying is that when you buy insurance, or have insurance provided through your work, it's like a coupon for money off your doctor bills.  The doctor NEVER gets 100%.  As a consumer of healthcare services, you need to think "coupon".  I've started to look at my insurance that way, and realize that MOST insurance is to keep you from going bankrupt if something bad happens.  It's not for every sniffle, fever, lump or bump. 

Deductibles are going to continue to go up as it gets more expensive to even have insurance, so we all need to wrap our head around what the definition of insurance is.  I have an odd perspective on this.  I'm a consumer, my husband is a provider, and I'm a biller of health services.  I have to see all sides.  I long for the days of straight 80/20 insurance, but that is no more.  We all better get used to it!

I'm sorry if that's harsh.

[bumbleb]

I agree with DMK. I also see all sides. But there are also much lower premiums for the higher deductible plans. So the patient saves money/month.

For example, in my family, a BCBS policy with straight $15 Dr/$30 Specialist copay it costs about $1000/month. But a ~$5000 deductible plan costs $400-500/month. So I would be saving $6000-7000 /year if I don't have to use it. It's a gamble. The Dr has to take the same write-off either way.

We have patients who have had up to a $10,000 deductible (ouch), but the monthly premium is so much lower, they usually won't come close to it, but it will cover them from something major. What they save monthly makes it worth it to them.

We used to have almost all our patients that just had to pay a copay. Now the majority have deductibles to meet - whether it's a personal plan or employer plan. It just costs too much in premiums to have anything else...but that's a whole other conversation!

[PMRNC]

There is an an EXCELLENT resource/book called "Understanding Health Insurance"  by Joanne Rowell,   she updates this every couple of years and I have every edition. I worked for a few diff insurance carriers and this book still is my "GO TO"  She covers every plan type known, COBRA, MSP, Tertiary rules, COB rules, Workers Comp, PI, etc etc etc.    The latest edition I have is 10th edition, but there could be an 11th edition out now or soon to come. You can also get the accompanying workbook and there's a CD in back of them as well (most of the later versions)   I STRONGLY urge ANYONE doing medical billing to get this book You will come to understand how ALL of the various plans out there work.   I had the privilege of meeting and talking with Joanne Rowell a few years back and she KNOWS her stuff..