Hi everyone, this is Sam Collins, your coding
and billing expert for acupuncture for the American Acupuncture Council Information Network,
and thank you for spending some time with us today. As always, we hope we’re giving
you some information to help enhance and increase your practice. As always, brought to you by
the American Acupuncture Council. Again, my email here if you want to go to the slides,
my email is my name, [email protected] We’re always here to make a little bit of
help for you, whether its seminars or network program and so forth. But today’s program, let’s talk a little bit
about just standards and practices, but specifically policies relating to cash, insurance and how
they comply. One of the things we always have to make sure is that we always have a compliance
in our office. Well, part of that compliance is, how do we really comply, how do we really
work with a practice that does both? Can I have a practice that does cash and insurance?
Are they mutually exclusive? Is it worth it even doing it? I would certainly having a practice that does
a little bit of both is probably to your best advantage, because I want patients that can
come into me. Whether they’re going to have insurance, whether they’re going to have cash,
I want to see them. The difference I want to discuss today though is can I have a difference
in price? Can we do anything that makes it potentially more attractive for a cash patient?
Can I give a cash discount? That’s really what I want to hit on. Is there
an ability to do a discount? Well, here’s something we all know. The National Institutes
of Health indicated, and they did a study, that revealed coverage patterns for acupuncture
specifically are not as good. Well I don’t think they so much needed to do a study, they
probably could have called any acupuncturist and we certainly could have told them about
that. That being said, here’s what the data suggests. Data suggests that Americans are
increasingly willing to pay out-of-pocket for acupuncture. Specifically, obviously,
when it’s not covered by insurance. Since it’s not covered, they’re more used to it.
So again, that’s what the study shows. So since people are willing to pay out-of-pocket,
of course many acupuncturists say, hey I’m going to do a practice that does all cash.
Which is certainly your right to do, but I would just suggest if you have an insurance
patient, what can we do with insurance that’s different from cash, can we give a discount? Now here’s where I want to be careful. Often
people will say, I’m giving a cash discount. And in fact, I would argue and I will state
you, you really don’t give a cash discount, but you potentially give a prompt pay discount.
But before we start even with that, let’s talk about waiving. The one thing we want
to be careful is waiving fees, waiving amounts, waiving deductibles. So take a look here.
Here’s what is says by Office of Inspector General. Waiving co-payment, co-insurance
and deductible. If a physician’s office routinely fails to collect the patient’s portion of
care, it’s considered a violation of both the anti-kickback statute and false claims
acts. Now what does this mean? If I billed insurance
$100 and the patient has a deductible and I do not collect it, it’s a false claim because
I billed money that I’m not intending to collect. So bear in mind that that’s where this issue
of a false claim comes in. It’s also potentially considered a kickback because if you’re waiving
a patient’s deductible, it’s like you’ve given them that money. So now here I want to highlight again one
more thing that it says here in that first sentence. If a physician’s office routinely
fails to collect. So notice here where it talks about down here, and I’ll point to it,
but they also recognize when a physician makes a reasonable effort to collect from a patient.
So for instance, you bill an insurance, but the patient simply doesn’t pay the rest, you’re
not going to be in trouble for that. Obviously, you’re going to do the best you can to collect,
but no one’s ever going to force you that if you didn’t at least do a reasonable attempt
to collect, if you didn’t it’s not the issue. The key here is routine waiver. Please be
sure. Obviously when patient’s have insurance, sometimes they just don’t make the payment
or we have other issues, but the routine waiver’s going to be an issue. Here’s what we want to focus on. Can we give
any type of discount? Well, in most states the answer is no. There’s no discount when
it comes to paying cash. However, what it says from the Office of Inspector General,
and specifically from the OIG Opinion 08-03, it says, following a broad guideline, they
okayed a 5 to 15 percent prompt payment. Now I want to be clear, this is not cash, it’s
basically pay at the time of service. Now obviously that could be cash, but it could
be a check, could be a credit card, so realize it’s payment at time of service. What they okayed is 5 to 15 percent, and in
my opinion, I think that does make sense because it does cost money and time to bill insurance.
By the time you fill out a claim form, verify insurance, send the claim, wait for payment,
adjust the claim, send the patient, its turned out that 5 to 15 percent of the money that
you collect went to administrative. So with this prompt pay what you’re doing is passing
along a bookkeeping savings. In other words, because you do not have to bill insurance,
your saving yourself the time and effort, whether it’s you or staff to billing, and
you’re giving them 5 to 15 percent. So what you want to think of, is this defensible?
Is it an actual bookkeeping? What if you said, hey I got a cash price that’s $50.00, but
insurance price is $100.00, that would be unreasonable and the reason it is, it doesn’t
cost $50.00 to bill insurance. I will certainly say it takes extra time and effort, but it
doesn’t cost double. So always think of keeping it fair and reasonable. So charging 5 to 15
percent more or discounting 5 to 15 percent for someone paying cash is certainly reasonable.
And again I want to emphasize, I said the word cash, but do keep in mind what it really
is is prompt pay. Pay me today. So keep that in mind. However, there is always hardships. Hardships
are a whole different issue. You might have a patient with a hardship that they may pay
you nothing. They come in, they can’t afford it, but you want to help them. You’re a healthcare
provider, there’s nothing wrong with you going ahead and doing that service for free or at
a very discounted rate. Hardships are always acceptable, but do make sure that it’s a legitimate
hardship. Obviously you’ll see here some talk of you have to verify their tax returns. I
would say keep it reasonable to understand that. Have them sign a document where they
understand that it is a hardship, then that way we have no issue with them coming into,
allowing there to be an issue of them saying you cheated the system. The key issue here
is if you’ve given someone a hardship, please make sure that the hardship price is the receipt
they are given. Don’t give a patient a hardship and then in turn have a receipt that shows
your regular price or they may submit to insurance. If they’re getting a hardship, everyone else
gets a hardship meaning anyone else that’s going to pay that bill. But hardships are
acceptable and don’t be afraid to do them. Now some states do allow a very broad allowance
of a discount. So I’ll give an example. For anyone that’s in California, and I’m not doing
this to entice you to move to California, but you’ll see here it says California Business
and Professions Code 657, and this is what the law says. I’m going to blow it up a little
bit. It says here, to encourage the prompt payment of health or medical care claims,
healthcare providers are hereby expressly authorized to grant discounts in health or
medical care claims when payment is made promptly within the time limits prescribed by the provider.
So what they’re referring to here is that it’s a prompt pay, but it’s the prompt pay
that you decide in California. So in other words, it doesn’t have to be pay at the time
of service as it would in most states. But the other interesting part for California
is the allowance they have. So take a look here. Any discounted fee granted pursuant
to this section, shall not be deemed a healthcare provider’s usual, customary or reasonable
fee for any other purpose. Not limited to, any healthcare service plan. So in other words,
in California when someone doesn’t have insurance and paying cash, you can charge them a price
that could be very different from their health insurance price, or your health insurance
price. Now bear in mind that’s a California only rule. That’s not in any other state.
The only other state that has something like that is Minnesota that has kind of the same
rule. Be careful, know your state and most states
the discount can be for prompt pay and 5 to 15 percent. But keep this in mind. You’re
going to bill a fair fee for service, whether your insurance pays for it or the patient
pays for it, I want the fee. Insurance billing is a little bit of a hassle, so I will certainly
say it appears to me to be reasonable to give a small discount for pay at time of service
and charge a little bit slightly more, but be careful of making it where it appears that
you’re cheating the system. In my opinion that’s really where you want to look. So, California’s got a pretty nice rule for
this, but what could we do also beyond just the pay at time of service? There is something
that we call concierge or sometimes you’ll hear as retainer agreements. These are the
states that allow retainer agreements and these are the ones that I could definitively
say do. However, most states will usually allow a retainer and what that retainer means
is that the patient has bought a set number of services. So I want to be very careful
here to make sure that you understand that please take a look at your own state, but
here’s the basic rules of these retainer agreements. In other words, it’s a prepayment for services. So what does prepay mean? It’s a payment for
a set number of visits. So for instance, in Maryland this is allowed, and they allow you
to sell a number of visits to a patient and those visits can be at a cheaper rate. So
instead of maybe $100.00 a visit, if you buy 10, maybe you sell them for $800.00. The issue
here is that it must be a set number of visits. It cannot be for a period of time. You can’t
say get unlimited visits for a month versus a set number of dollars, but it has to be
a set number of services. In addition, there must be no expiration. You can’t tell the
patient they have to use it within a certain time, you can encourage it, but you cannot
force that. In addition, there must be a refund policy
for unused. So, if a person buys 10, they can certainly use them all right away or they
might use them over a few months, but if they don’t use them all and they want to no longer
come in, it is their right to seek a refund and they get a prorated refund. So in other
words, if I pay $500.00 for 10 visits and I only use five, the patient gets refunded
$250.00 or what they didn’t use. Realize this contract could be rescinded by either side
as long as you put it in the contract with the patient, but make sure it’s a return of
money. Realize that, don’t play games. If a patient doesn’t want to continue care, don’t
fight with them. Most patients who buy prepay really like you,
they want to come in, they just understand the value and since they know they’re coming
for a lot of visits, certainly something that you may allow. I would in fact encourage,
potentially might be something a family wants to purchase that several family members can
use the visits. This is generally not allowed for insurance reimbursement, and specifically
in the state of Oregon, they don’t allow for insurance reimbursement, so if a patient comes
in and uses this, please make sure they’re aware they cannot submit to their insurance
company for it. But in some states they might. So bear in mind, the patient’s receipt will
only reflect the amount that they paid. So when they come in, if you buy 10 for $1,000.00,
each time they come in, you could give them a receipt for $100.00 for the visit to bill
insurance. You can give a simple receipt for the amount they paid, but as far as reimbursement,
it has to be prorated. The other factor that you may run into here
is that some states may require the money be placed in a trust account. Typically in
the state of Texas and Florida, this may be the case, so if you’re in those states please
verify and in any state verify whether or not they allow you to hold the money. In other
words they want it in a trust so that way if something happens to you, the patient’s
money is still available so that way they can be refunded should you not be able to
complete the care. I think this is a viable for patients to understand healthcare, that
want to have health and more of a supportive care. So I think this could be a nice way
of allowing you to have a difference. Again, can you have a large cash discount
at the beginning of care? No, but you can give a 5 to 15 percent prepay … or excuse
me, prompt pay. But what if they prepay visits. Now the prepay visits don’t have the 5 to
15 percent reduction. Here it’s allowed to be any amount you want, but again make sure
that it’s fair and that there is a refund policy. My best to you to continued success. Please
take a look, go to our website. It’s www.aacinfonetwork.com. Take a look at all our services. We have upcoming
programs for you. Our goal is to continue to make you successful. All our programs are
continued education, they’re certified for additional hours and we want you to be successful
and I wish you the best. Next week’s host will be Virginia Doran. Thanks
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