General Category > General Questions

"Time of Service" Discounts?

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PMRNC:

--- Quote ---I was just wondering - becausemy clients generally stick to a consistent percentage discount.  But they don't hesitatate to vary from that when the patients circumtances call for it.  But that is generally only when they are not PPO for the patient's insurance.
--- End quote ---

And that is fine, what I was trying to say is that if they have a financial policy in place and want to make an exception on case-by-case basis they can but IMHO those should be documented as financial hardships and the office policy will state those circumstances. Then you never have to second guess yourself (as a physician).   
 

Billergirlnyc:
Linda pretty much answered this question. I'm not a healthcare lawyer, but I have one. So know these are ONLY my opinions and no I won't go find cases or laws, that's for anyone who needs this info to do. I mean no offense, just wanted to preface my comments.

As to the this whole "time of service discount" - it's  tangled web, and while I didn't want to write a book, MY opinions are below:

This is huge now and has been since the recession. It's such a real thing to stay on top of because federal and state laws. Some states have requirements, some plans the providers are PAR with have these "most favored nation" clauses, some states consider it a kickback so it's prohibited in states with kickback laws, some states have anti-discrimination laws which essentially says you can't charge a certain amount of payers differently than you would the next. I could go on and on. My attorney required I attend a webinar they gave for those in the admin side of healthcare (billers, administrators, etc) before they would sign me on as a client. Then, of course, you have financial hardships they could sign, but even that's tricky. Then you have Medicare and Medicaid rules concerning this as well as concerning financial hardships - they want thorough documentation of financial hardship. As my attorney always says he tells his physician clients: Exercise extreme caution because things can go bad really quick when you factor in the anti-inducement provision of HIPPA, the Medicare exclusion provision, state anti-kickback statutes, and state insurance anti-discrimination provisions/laws. I also remember him telling me that he considers any discount a doctor gives to a patient some sort of kickback, because the doctor is returning a portion of his/her fee to the patient. 

Not here to debate the law. I only add of this to show how slippery this is and every provider we sign on should have provisions in place to ensure they're not violating any laws that prohibit them (because of a plan their in, or whatever reason) from offering "time of service discounts", and by default their billing and admin staff should understand the rules, regulations, and policies in place to ensure everyone's on the same page and following protocol. I know plenty of doctors who think if it's a non-covered charge then they don't have to heed to any law or regulation, but even this isn't true. The same goes for NON-PAR providers (aka out-of-network providers). I always tell clients when they ask me about this. I can tell you what I know, but call your lawyer too. What's your policy on financial hardships? Why are you giving this patient a discount?. Just because I may not be billing the patient's insurance doesn't mean you shouldn't be following protocol, which must be set by the client. I need them to stay in business so I do too. Not just that, again, you'll have a provider who will collect monies from a patient then tell you to bill what they collected and it's less than what they would normally charge the carrier. No, we need a system in place before this happens, or before you eat someone's deductible, or waive a copayment (which we know are part of the doctor's payment too).

Some things go above the idea of me or my billing company getting trouble and land directly on trying to keep my clients in business. So the more informed I am about potential issues, the better for us all. That's how I look at most things in life and in business.

RichardP:
The original question was: what is the legality of it all?

Personal opinion does not answer this question.  References to ethics does not answer this question.  Either I don't know, or links to relevant regulations, would answer the question.

Linda, you said ... an office has a financial policy in their office (AS THEY SHOULD) ...  I'm not trying to be difficult here.  Your readers deserve an answer.  WHERE is the regulation that leads you to believe that they should have a financial policy?  You obviously believe that a financial policy is a protection against something.  What is that something, and where is it defined.

Billergirlnyc, you said ... As my attorney always says he tells his physician clients: Exercise extreme caution because things can go bad really quick when you factor in the anti-inducement provision of HIPPA [Federal], the Medicare exclusion provision [Federal], state anti-kickback statutes [state], and state insurance anti-discrimination provisions/laws [state].  That's a better start, because it gives the reader something concrete to research on his own.

However, price discrimination by physicians and hospitals is legal.  The Robinson–Patman Act of 1936, an amendment to the Clayton Antitrust Act, prohibits price discrimination - but only for commodities.  It does not prohibit price discrimination for services.  And hospitals and insurance companies and doctors do engage in price discrimination - all quite legally.  For those interested in more information, Google on "price discrimination" + healthcare (or 'doctors').

Billergirlnyc, because price discrimination is legal for doctors, I take issue with this statement in your response:  I also remember him (healthcare attorney) telling me that he considers any discount a doctor gives to a patient some sort of kickback, because the doctor is returning a portion of his/her fee to the patient.  There is no legal requirement anywhere that I am aware of that a doctor must post his prices so potential patients can comparison shop.  In fact, the criticism of the health-care industry is just the opposite:  there are no price lists for doctor or hospital fees such that potential patients can comparison shop.  And because of this, there is no competition.  And because there is no competition, prices are higher than they would otherwise be.  All of this leads to the following fact:  the doctor's fee is what he charges his patient.  The charge given to the patient sets his fee for that patient.  The fact that he might charge someone else 10% more or 20% more has no bearing on what his fee is for this particular patient.  The doctor's fee is what he charges the patient.  Your lawyer may be erring on the side of caution, but he is making an economically-incorrect (and probably legally incorrect) statement to say the doctor is returning a portion of his fee to the patient - because there is no law that says a doctor or hospital has to charge the same fee (and publish a list of fees) for the same service to every patient.  Google and read as I recommended above and you will see that this is not just my opinion.

Even though the law allows a doctor and a hospital to charge whatever they want to whomever they want (for services rendered), this freedom is constrained in certain circumstances.  And Billergirlnyc points to some areas where these constraints might kick in; e.g., a doctor's contract with an insurance carrrier (including Medicaid and Medicare), HIPAA and ACA requirements, and any state regulations.  But these regulations only constrain price discrimination in pre-defined circumstances - they don't prohibit price discrimination in all circumstances.  Therefore, it is to a doctor's benefit to consult with a health-care attorney who knows which state and Federal regulations will constrain that particular doctor's practice.  And if this is what Linda meant by having a financial policy in place, then I agree with her - it makes sense to have the lawyer's finding compiled into a format that can be readily accessed and looked through re. what regulations constrain that particular practice with regard to price discrimination.

PMRNC:

--- Quote ---Linda, you said ... an office has a financial policy in their office (AS THEY SHOULD) ...  I'm not trying to be difficult here.  Your readers deserve an answer.  WHERE is the regulation that leads you to believe that they should have a financial policy?  You obviously believe that a financial policy is a protection against something.  What is that something, and where is it defined.
--- End quote ---

I'm having a hard time thinking anyone is going to think it's incorrect or wrong to say the provider should have an office policy. Is it a law? Dang if I know but whether it's a law or not is MOOT/IRRELEVANT as I have never and most likely will NEVER encounter a provider who will say "No, I don't want an office financial policy, I don't want to be protected from accusations of playing favoritism or other mis-doings. "     I DO believe a financial policy IS protection against some things as long as it's adhered to. Example:   Dr. Smith knows Mrs. Jones husband just lost his job. She is one of his long standing clients. She used to get a 20% discount (NO insurance, cash pay), but has asked if she could receive a further discount.  Mr. Smith does NOT have to look to his own empathy or compassion, instead he can approach it from a business stand point and tell her, well let's take a look at what we can do, give her the form to complete for financial hardship (the ones my client gives out have an agreed time limit to which can be reviewed for extension later, this allows the provider to be mr/mrs. nice guy/gal and give patient a break but when their situation improves they can review additional extensions or discounts.)   This also allows Mrs. Jones to see that Dr. Smith has a clear policy, is also in business and is also suffering from cut backs with the rest of the country, and that he has taken the time to implement a uniform and FAIR policy for all patients."    Now if any provider needs a legal definition on said requirements of this policy, I won't look it up, I will not waste my time.   That is no different than you asking me for the legal source of a pizza shop's requirement of purchasing Pizza dough.  A law might NOT exist that says a pizza shop owner must have pizza dough, but by golly what a mistake it would be not to have pizza dough in the pizza shop.  :o :o :o ;)   I'm sure I can come up with many many more REALISTIC and maybe NOT legally required instances on how an office and financial policy would be advantageous to an office so unless you have some examples or instances where it would HURT the practice, I suggest we use the time more wisely talking about creating better work ethics to help our clients out instead of looking for laws that don't exist or should be replaced with downright common sense and ethics huh?  If that does not suffice I give the following disclaimer:

"The opinions and responses, expressed here, by me are those of the authors and do not necessarily reflect the positions of any US or State regulatory body, organization, group or agency. If you disagree, feel free to do your own research or speak with your own legal counsel."


Billergirlnyc, you said ... As my attorney always says he tells his physician clients: Exercise extreme caution because things can go bad really quick when you factor in the anti-inducement provision of HIPPA [Federal], the Medicare exclusion provision [Federal], state anti-kickback statutes [state], and state insurance anti-discrimination provisions/laws [state].  That's a better start, because it gives the reader something concrete to research on his own.

Well, is there a "reader" here who feels they need to research the legalities of an office/financial policy?  or the plain fact that Dr. Smith giving Mrs. Jones an additional % off and straying from his own financial policies is a good idea? (legal or not)   Again, I deal with pediatrician's and moms DEF do talk about their pediatricians to other moms. It's a REGULAR occurrence. It's NOT unusual for me to get a call from one mom asking why her friend came in and only paid the doctor $10  when she had to pay $20 (YES it happens all the time)   

 
--- Quote ---All of this leads to the following fact:  the doctor's fee is what he charges his patient.  The charge given to the patient sets his fee for that patient.  The fact that he might charge someone else 10% more or 20% more has no bearing on what his fee is for this particular patient.  The doctor's fee is what he charges the patient.  Your lawyer may be erring on the side of caution, but he is making an economically-incorrect (and probably legally incorrect) statement to say the doctor is returning a portion of his fee to the patient - because there is no law that says a doctor or hospital has to charge the same fee (and publish a list of fees) for the same service to every patient.  Google and read as I recommended above and you will see that this is not just my opinion.
--- End quote ---

Great.. we understand you have no problem with the doctor just making random and arbitrary arrangements with patients. Your job is then easier, but let us do what we feel in the best interest of our clients. We, no, I'll speak for myself, would rather air on the side of caution and add COMMON SENSE to the mix, and spend my time much more efficiently that working with providers who are not interested in right and wrong unless I legally prove it to them. If I had a client that was randomly giving away the farm to some and not others, didn't have an office/financial policy, and didn't care enough to put his business first, then, I'm not needed and my time is better spent with clients who do want to do the plain ol "RIGHT" thing.   I do feel better your picking on others and not just me <g>


--- Quote ---And if this is what Linda meant by having a financial policy in place, then I agree with her - it makes sense to have the lawyer's finding compiled into a format that can be readily accessed and looked through re. what regulations constrain that particular practice with regard to price discrimination.
--- End quote ---

That is ONE of reasons yes, but mainly again, my interests serve my client. If he doesn't have to be Dr. Good Guy all the time at the risk of his revenue and has a PLACE to go and use to fall back on that keeps him from being the evil or unfeeling doctor, that's another reason.  I have clients who tell me that their office and financial policies have saved them from their bleeding hearts many times over.  I've not had one argue a reason not to have one or challenge any legality of not having one.

Billergirlnyc:

--- Quote from: RichardP on February 02, 2013, 05:54:03 AM ---The original question was: what is the legality of it all?

Personal opinion does not answer this question.  References to ethics does not answer this question.  Either I don't know, or links to relevant regulations, would answer the question.
--- End quote ---


--- Quote ---Billergirlnyc, you said ... As my attorney always says he tells his physician clients: Exercise extreme caution because things can go bad really quick when you factor in the anti-inducement provision of HIPPA [Federal], the Medicare exclusion provision [Federal], state anti-kickback statutes [state], and state insurance anti-discrimination provisions/laws [state].  That's a better start, because it gives the reader something concrete to research on his own.
--- End quote ---

Excuse me a "better start" ? Listen, sir, I will contribute to any topic I feel like. So, thanks for the advice, but NO thank you on how I should've started it. And everything I stated is a starting point for anyone who knows how to sift through comments and gather the meat. If my comments don't pass your test, then by all means, scroll right past them. I contribute like everyone else and the only standard I will beholden too are the forum's. No where do the owners require someone to put a million links or case studies. If that's what you like doing then by all means do it, but please don't try to dictate how I respond to a topic. Thank you.

Also, I've yet to meet someone who is an attorney on here and even if I did, they too, would put up a disclaimer. My personal opinions are also my professional opinions. I don't need to defend my responses or my experience. My comments are always meant as a stepping stone, a point of entry. If someone needs to be sure I know what I'm talking about then I suggest they go and do their own research, because I'm not going to debate ANYONE about the legalities of anything, because it's beyond the SCOPE of my knowledge, and NO ONE should be taking anyone's word on a public or even private forum at face value. Even if there are links, I STILL ask my attorney, thus me prefacing my comments.


--- Quote ---However, price discrimination by physicians and hospitals is legal.  The Robinson–Patman Act of 1936, an amendment to the Clayton Antitrust Act, prohibits price discrimination - but only for commodities.  It does not prohibit price discrimination for services.  And hospitals and insurance companies and doctors do engage in price discrimination - all quite legally.  For those interested in more information, Google on "price discrimination" + healthcare (or 'doctors').
--- End quote ---

Did you even read what I said? I said "state insurance anti-discrimination provisions" - NO WHERE do I say it's illegal, and nowhere did I state that MY attorney says it's illegal HE SAID "exercise extreme caution" on all the aforementioned matters. Please READ what I said. Please consult your attorney if you want to debate this, he/she has the license and scope of training to do that. I'm not a lawyer and don't dole out legal advice. If anyone else has a question, please consult your attorneys or AN attorney (including the anti-kickback laws in your state and in reference to doctors). Don't ever just take my word or anyone else's word at face value, and certainly don't think because someone throws-up case studies or links that's all you have to do. Some things really do require us to spend money for an expert and not just consult google or a forum ALONE.

I've contributed what I could and I stand by everything in my original comment. I implore all who read my comments to source facts for yourselves. And I will continue to respond to any topic I feel like I can with personal and professional opinions, if that's not good enough for you, then by all means ignore and or scroll past mines. I won't be offended.

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