June 2018 Client Newsletter
Professional Courtesy / Insurance Only
Professional Courtesy and "Insurance Only" billing is very risky. The co-pays, co-insurance & deductibles are intended to be disincentives to over-utilization of care.
But please beware of the risks of audit that could result in:
- Take back of the full insurance payment, and
- Referral for a fraud investigation.
That isn't to say Professional Courtesy isn't common. While we have not heard of an audit specific to Professional Courtesy, we are hearing about more and more audits from both Medicare, Medicaid & Horizon. If you follow the CMS and various other audit reports, each year the amount of money recouped has increased in nearly all cases. The safest way is to not bill at all for the service.
I don't have an answer for Professional Courtesy, the AMA has a 2 page article that sort of minimizes the issue until the end of the article when it points out the risk. If you would like a copy, let me know.
Two other points:
- Just a reminder that if a patient has documented financial hardship, that is acceptable to write-off patient balances as long as it falls within the office's written Financial Hardship policy.
- Billing for services without co-pays/deductibles/coinsurance that are paid in full by insurers (e.g., well visits) should be safe to do. In that case, since there is no patient responsibility the disincentive would not apply.
Worker's Comp & MVA Patients
When a patient presents wanting you to bill worker's comp or MVA insurance, be sure your office calls the adjuster to verify benefits. We recently had a patient receive services whose W/C case had been closed - and the insurer predictably denied coverage. To re-open the case, the patient has to request it. It is NOT W/C until the W/C insurer accepts it as W/C and issues a Case Number.
The only way to protect yourself from this, and ensure you will be paid, is for your office staff to require the patient to provide FULL W/C insurance information prior to being seen, verify it is an open case, and that they will pay you as a provider. To do so, collect from the patient:
- Insurance Company name,
- Adjuster's name & phone #, and
- the Case #.
Your office must then call and verify the information provided. Often these patients can only see providers approved by the W/C insurer. If your office is not on that list, you may not be eligible for payment. Your office should document who they spoke to, the date, what was stated (did the Adjuster agree your office will be paid?), etc. Always ask them to fax you their confirmation.
On a related note, you are allowed to see the patient on the same day for 2 separate & distinct services and be paid. For instance, a patient can be seen for BOTH W/C and for his/her unrelated medical issues (heart disease, diabetes, cold, flu, etc.). What is critical is that the documentation MUST clearly be separate and distinct. One note must include the full discussion for the W/C - and the other the unrelated medical issues. Some auditors advocate having 2 separate EHR events, others agree that as long as they are separate and distinct it is ok. Our view is that either is fine as long as properly constructed to clearly show the separation of services. For an EHR, be careful not to "clone" the notes unless relevant, and to code the correct level of service for each.
Of course, you could also see the patient on separate days.
Effective 5/1/18: United Healthcare Will Require Anatomical Modifiers
UHC announced in its February 2018 Bulletin that claims for services performed on the eyelids, fingers, or toes submitted on or after 5/1/18 will require anatomical modifiers. Claims that do not include the anatomical modifier after 5/1/18 will be denied, but may be resubmitted for payment with the appropriate modifier.
NEW Medicare CARDS
Just a reminder that the new Medicare Cards will start to be sent out After April 1, 2018. This is no different than any other insurance card changing - OTHER THAN the fact that it will happen for ALL Medicare patients. So just continue to ask all patients if their insurance has changed, and when it has, obtain a copy of the insurance cards and forward to CPB.
Medicare will not be updating all at the same time - the new cards will be spread out over time so a Medicare recipient may not have their new card yet. Remember also that the new cards will not have Social Security #'s on them.
PLEASE note: the Medicare Beneficiary Identifier (MBI) Lookup Tool that Novitas offers will allow providers to obtain their patient's MBI number BUT requires the patient's Social Security # in order to do that lookup. The MBI Lookup will require users to enter the patient's First and Last Name, Date of Birth, and Social Security Number (SSN) to search. So, please continue to request Social Security #'s from all patients (which is also useful to the collection agency).
One point regarding Railroad Medicare (RRMC). In the past their policy # somewhat unique such that it was obvious it was RRMC. With the new cards, that will no longer be the case since they are using the same policy format as traditional Medicare. The only difference is "Railroad Retirement Board" is specifically written at the bottom of the new cards. Other than that, the cards are identical.
Patient Sign-in Sheets - HIPAA Requirements
We occasionally get asked what the requirements are for the patient sign-in sheets. Do you have to use the "tear off" type so you can remove the name each time a patient signs in? Rather than offer an interpretation, here is the answer copied direct from HHS:
May physician's offices use patient sign-in sheets or call out the names of their patients in their waiting rooms?
Yes. Covered entities, such as physician's offices, may use patient sign-in sheets or call out patient names in waiting rooms, so long as the information disclosed is appropriately limited. The HIPAA Privacy Rule explicitly permits the incidental disclosures that may result from this practice, for example, when other patients in a waiting room hear the identity of the person whose name is called, or see other patient names on a sign-in sheet. However, these incidental disclosures are permitted only when the covered entity has implemented reasonable safeguards and the minimum necessary standard, where appropriate. For example, the sign-in sheet may not display medical information that is not necessary for the purpose of signing in (e.g., the medical problem for which the patient is seeing the physician). See 45 CFR 164.502(a)(1)(iii).
Sign-in sheets are fine as long as they don't contain Protected Health Information (PHI). A name by itself is NOT PHI. The confusion comes about because everyone seems to think "names" are PHI-they are not. The definition of PHI in the HIPAA regs requires an identifier plus health information to constitute PHI.
Thus, sign-in sheets with just names are fine, as is calling out patient names in the waiting room.