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Practice Management Q&As


When a patient fails to meet a copay

Q. I have a few patients who repeatedly fail to come up with their copay at the time of service. In a nonemergency situation, is it illegal or unethical to turn them away?

A. As long as you're not abandoning your patient-ending the doctor-patient relationship before treatment is finished-there's no ethical and probably no legal obligation to see someone who habitually refuses to pay you. However, before you turn anyone out the door, make sure you give all patients formal notice that in order to be seen, they must pay their copay at time of service. Post an announcement of this policy in your waiting room, or give patients a copy to sign, indicating that they've read it and have had the opportunity to ask questions.

More and more doctors are turning away patients who don't have their copays. But of course, be sure to check with your managed care plans before implementing such a policy.

Would doubling a dosage really hurt?

Q. A managed care patient asked me to alter her prescription for antidepressants so that what would look like a one-month supply of drugs would actually be a two-month supply. (She wants me to prescribe 40 mg/day instead of the 20 mg she actually needs. But since she'd continue to take only one pill, the prescription would last twice as long.) The patient is experiencing financial difficulties and this small favor would help her out a lot. Should I bend the rules?

A. It's a bad idea. You may have to answer to your managed care company if the pharmacy questioned the doubling of your patient's dosage, and that could threaten your participation with the plan.

If you become your hospital's landlord

Q. I'm thinking of purchasing the office building where I practice in a hospital-owned primary care clinic. If I did that, I'd become the hospital's landlord. Would that arrangement violate the Stark law, because I frequently refer patients to the hospital?

A. No, you wouldn't violate the Stark law, which prohibits doctors from referring Medicare and Medicaid patients for certain services to entities where they (or members of their immediate families) have a financial interest. Your ownership of the building the hospital's clinic occupies isn't considered a financial interest in the hospital itself.

However, there might be an antikickback issue here. Antikickback laws say you can't refer Medicare and Medicaid patients in exchange for remuneration of any kind. That potentially could include rental payments to you as the landlord. Fortunately, there's a "safe harbor" that will protect you from antikickback rules: Make sure you have a written lease for the term of at least one year, and charge fair market rent. Check with your healthcare attorney to make sure the deal is structured properly.

How long to keep billing records

Q. How long should we keep EOBs and encounter forms? Storing them consumes a lot of file space, but scanning is not an option for us right now.

A. For your own accounting purposes, you'll want to keep them about three years. Any problems should show up during that time. However, Medicare and other payers can look back further. Medicare can recoup overpayments going back four years-or even longer if fraud is established. The False Claims Act-which makes it a crime to submit false claims to the government-generally provides a six-year limitation, but may go back as far as 10 years.

Sharing an office . . .and liability?

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Jennifer N. Lee, MD, FAAFP
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health