Practice Management Q&A

March 21, 2008

Waiving copays; claims denial; retirement

Waiving copays for financial hardship

I sometimes waive coinsurance for patients struggling to make ends meet. I tell them to ignore the bills and collection letters I send because I'll just write off their balances as bad debt. Is this legal?

Probably. Granting routine waivers could be considered fraud under state and federal law. However, physicians are generally permitted to waive copayments in particular cases of financial hardship. To steer clear of any semblance of fraud:

Fears regarding a free answering service

The hospital where I have privileges provides a free answering service. If a patient or physician needs to speak to me after hours, he calls the hospital, and the operator there forwards the call to my cell phone or pager. Am I violating antikickback laws by accepting this service?

It depends. Such a benefit-when offered free or for a low fee-must meet certain criteria to comply with Stark rules.

Under Stark, your answering service must be reasonably related to the provision of-or designed to facilitate-medical services at the hospital. It can be used only on the hospital campus or to access information on patients and personnel who are there, and during periods when the medical staff members are making rounds or engaged in activities that benefit the hospital and its patients.

Your arrangement sounds like a normal answering service-albeit routed through the hospital. It allows patients and physicians to contact you, whether or not their call has anything to do with hospital services. To avoid any appearance of soliciting a kickback, the hospital should charge doctors a fair market fee for this service.

When a carrier denies clean claims

What can you do when an insurance carrier continues to deny clean claims?

First, collect your evidence. List all denials, with their dollar amounts, sorted by type (for example, E/M with procedure code). Next to each, note the rule that supports your correct coding of the claim.

With this information, make your case. Hopefully, you and the carrier's rep can clear up anything your office may be doing that triggers the denials. Be prepared to negotiate over claims that may be debatable. If you're not satisfied with your carrier's response, calculate the percentage of your revenue that comes from this payer. If you can afford to, consider dropping the contract.

If you decide to bail, check your contract's renewal date and find out when you have to give notice of nonrenewal. At that time, send a letter via certified mail notifying the carrier that you intend to drop their contract and explaining the reason why-because they regularly deny clean claims.

Making red tape work in your favor

A physician we hired didn't work out, so we had to let him go after a few weeks. At that point, his credentialing with Medicare still wasn't complete. How can we get reimbursed for the Medicare patients he saw?

Wait for CMS to finish his credentialing. When they notify you that it's complete, transmit all the claims for the patients he saw, using his new Medicare provider number for the practice. As soon as you've confirmed that Medicare has received the claims and is processing them, prepare a CMS 855R form, terminating his reassignment of benefits to the group.

Some Medicare carriers will allow you to sign this form, but others require the signature of the terminated physician. You'll have to contact your carrier to find out what its policy is. But by the time you obtain the proper signature, forward the form to Medicare, and they officially terminate the reassignment, you can be reasonably sure that you'll already have received payment for the services he provided.