NSAA 2014 conference

Third Party Billing forNon-physician Surgical Assistants

Issues and Trends

Third Party Billing forNon-physician Surgical Assistants

Issues and Trends

Luis F. Aragon, CSA,RSA, LSA

National Surgical Assistant Association2014 Annual Conference

Washington, DC

Terms to knowTerms to know

• Out of Network: It refers to a provider that does not have a contract with an insurance carrier.

• Out of network and in network out of pocket amounts are calculated separately.

• Out of Network: It refers to a provider that does not have a contract with an insurance carrier.

• Out of network and in network out of pocket amounts are calculated separately.

Luis F. Aragon, CSA, RSA, LSA

Life Cycle of an Insurance ClaimLife Cycle of an Insurance Claim


Clean claimClean claim


Patients can be billed for non-covered procedures, but not for unauthorized services. Claims are adjudicated by line item (not for total charges), which means that payers bundle and edit code numbers for individual procedures and services (Unless referred to third party companies for negotiation)The patient is responsible for co-payments and deductibles, but does not pay more than the allowed negotiated rate.

Patients can be billed for non-covered procedures, but not for unauthorized services. Claims are adjudicated by line item (not for total charges), which means that payers bundle and edit code numbers for individual procedures and services (Unless referred to third party companies for negotiation)The patient is responsible for co-payments and deductibles, but does not pay more than the allowed negotiated rate.

Facts to knowFacts to know


Out of Network Legislation examplesOut of Network Legislation examples

• COLORADO:West's C.R.S.A. § 10-16-704, "Network adequacy," mandates a certain payment level for claims filed by nonparticipating medical providers under certain specified circumstances.

• ILLINOIS1) covered services are not available from a contracted provider; and 2) the member has made a good faith effort to use the services of a contracted provider but such services are unavailable. In these instances, provider/payor agreements must contain a provision whereby the covered member will be provided a covered service at no greater cost than if such service had been provided by a contracted provider (50 IAC 2051.55 (e)(10)(A)).


No Out of Network benefitsNo Out of Network benefits


Co-insuranceCo-insurance


No balance billing allowedNo balance billing allowed

Luis F. Aragon, RSASurgbill

DeductibleDeductible


Co-insuranceCo-insurance


To bill or not to bill! (Patients)To bill or not to bill! (Patients)

This has been an issue of debate nationwide in the Surgical Assistant industry for decades now.Facilities and surgeons want the advantage of our services for free or for a minimal fee but do not want their patients to be bothered with an additional bill.We strongly recommend billing for deductibles and co-payments, but strongly advise against balance billing or when the plan does not have out of network benefits. (State based)

This has been an issue of debate nationwide in the Surgical Assistant industry for decades now.Facilities and surgeons want the advantage of our services for free or for a minimal fee but do not want their patients to be bothered with an additional bill.We strongly recommend billing for deductibles and co-payments, but strongly advise against balance billing or when the plan does not have out of network benefits. (State based)


AMA Council on Ethics and Judicial AffairsAMA Council on Ethics and Judicial Affairs

The AMA has acknowledged that routine waivers of coinsurance/deductibles constitutes fraud, and proclaims the practice to be unethical.

The AMA has acknowledged that routine waivers of coinsurance/deductibles constitutes fraud, and proclaims the practice to be unethical.

• http://www.ama-assn.org/ama/pub/category/4615.html


AMA Council on Ethics and Judicial

Affairs

AMA Council on Ethics and Judicial

Affairs

• Opinion 6.12 - Forgiveness or Waiver of Insurance Copayments:

Physicians should be aware that forgiveness or waiver of co-payments may violate the policies of some insurers, both public and private….. Routine forgiveness or waiver of co-payments may constitute fraud under state and federal law.

• Opinion 6.12 - Forgiveness or Waiver of Insurance Copayments:

Physicians should be aware that forgiveness or waiver of co-payments may violate the policies of some insurers, both public and private….. Routine forgiveness or waiver of co-payments may constitute fraud under state and federal law.


HIPAA Section 242(Public Law 104-191 104th Congress) Title II, Subtitle EHIPAA Section 242(Public Law 104-191 104th Congress) Title II, Subtitle E

Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice-- (1) to defraud any health care benefit program; or (2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 10 years, or both.

Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice-- (1) to defraud any health care benefit program; or (2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 10 years, or both.


Fraudulent & False StatementsFraudulent & False Statements Professional courtesy discounts in

the form of a waiver of a co-payment or deductible constitutes both health care fraud and false statements.

Knowing you are required to collect a co-pay or deductible but billing insurance only is committing health care fraud;

By billing an insurance company one charge but failing to collect the patient co-pay or deductible, the provider is making a false statement regarding the charge.

Professional courtesy discounts in the form of a waiver of a co-payment or deductible constitutes both health care fraud and false statements.

Knowing you are required to collect a co-pay or deductible but billing insurance only is committing health care fraud;

By billing an insurance company one charge but failing to collect the patient co-pay or deductible, the provider is making a false statement regarding the charge.


What Does OIG Say?What Does OIG Say?

In 1991 the Office of Inspector General (OIG) issued a fraud alert concerning the wavier of co-pays and deductibles. The OIG stated that billing “insurance only” may violate the False Claims Act, the Anti-Kickback Statute, the Civil Monetary Penalties Law, 42 U.S.C sec 1320a-7a(a)(5), as amended by Pub.L.No 104-91 sec 231 (h), and State laws.

In 1991 the Office of Inspector General (OIG) issued a fraud alert concerning the wavier of co-pays and deductibles. The OIG stated that billing “insurance only” may violate the False Claims Act, the Anti-Kickback Statute, the Civil Monetary Penalties Law, 42 U.S.C sec 1320a-7a(a)(5), as amended by Pub.L.No 104-91 sec 231 (h), and State laws.



• Routine Waiver of Deductibles & Coinsurance Prohibited

• 1994 Special Fraud Alert - http://oig.hhs.gov/fraud/docs/alertsandbulletins/121994.html

• 1991 Safe Harbor Regulations Alert – • http://oig.hhs.gov/fraud/docs/safeharborregulations/072991.htm

• Routine Waiver of Deductibles & Coinsurance Prohibited

• 1994 Special Fraud Alert - http://oig.hhs.gov/fraud/docs/alertsandbulletins/121994.html

• 1991 Safe Harbor Regulations Alert – • http://oig.hhs.gov/fraud/docs/safeharborregulations/072991.htm


http://oig.hhs.gov/fraud/docs/alertsandbulletins/121994.html

http://oig.hhs.gov/fraud/docs/safeharborregulations/072991.htm

http://oig.hhs.gov/fraud/docs/alertsandbulletins/121994.html

http://oig.hhs.gov/fraud/docs/safeharborregulations/072991.htm


• Waivers of Cost-Sharing Amounts For Financially needy Medicare & Medicaid Patients Permitted:

1) Waiver must not be routine;2) Waivers may not be offered through

advertisement or solicitation;3) Waivers may only be offered after

determining in good faith that there is a financial need or when reasonable collection efforts have failed

• Waivers of Cost-Sharing Amounts For Financially needy Medicare & Medicaid Patients Permitted:

1) Waiver must not be routine;2) Waivers may not be offered through

advertisement or solicitation;3) Waivers may only be offered after

determining in good faith that there is a financial need or when reasonable collection efforts have failed

• See testimony, Lewis Morris, Chief Counsel to OIG, 2004 http://oig.hhs.gov/testimony/docs/2004/40624oig.pdf


Best practice tipBest practice tip

Provide an Assignment of Benefits (AOB) to the patients to sign where they are allowing you to submit the claim to their

insurance company.

Provide an Assignment of Benefits (AOB) to the patients to sign where they are allowing you to submit the claim to their

insurance company.


A unique ten character alphanumeric code that enables providers to identify their specialty at the claim level.

Designed to categorize the type, classification, and/or specialization of health care providers.

Administered by the National Uniform Claim Committee which is chaired by the AMA with a critical partnership with CMS.

A unique ten character alphanumeric code that enables providers to identify their specialty at the claim level.

Designed to categorize the type, classification, and/or specialization of health care providers.

Administered by the National Uniform Claim Committee which is chaired by the AMA with a critical partnership with CMS.

Taxonomy codeTaxonomy code


• No, the codes are self-selected by the provider

http://www.nucc.org/index.php?option=com_content&view=article&id=97&catid=18&Itemid=128

• No, the codes are self-selected by the provider


Does choosing a taxonomy code mean I met the licensure / certification requirements for that provider?Does choosing a taxonomy code mean I met the licensure / certification requirements for that provider?


• You do not need to have that source’s certificationto choose the code. The sources for the definitions areonly to cite who authored the definition.


• You do not need to have that source’s certificationto choose the code. The sources for the definitions areonly to cite who authored the definition.


Do I have to have the definition source’s certification in order to choose the code?Do I have to have the definition source’s certification in order to choose the code?


The Health Care Provider Taxonomy code set is published(released) twice a year in July and January.The July publication is effective for use on October 1st

and the January publication is effective for use onApril 1st.The time between the publication release and the effective date is considered an implementationperiod to allow providers, payers and vendors anopportunity to incorporate any changes into their systems.


The Health Care Provider Taxonomy code set is published(released) twice a year in July and January.The July publication is effective for use on October 1st

and the January publication is effective for use onApril 1st.The time between the publication release and the effective date is considered an implementationperiod to allow providers, payers and vendors anopportunity to incorporate any changes into their systems.


When is the code list published?When is the code list published?



WHAT IS AN NATIONAL PROVIDER IDENTIFIER (NPI)?WHAT IS AN NATIONAL PROVIDER IDENTIFIER (NPI)?

• Is a healthcare provider’s unique 10- digit number used by insurance carriers to identify providers.

• Is a healthcare provider’s unique 10- digit number used by insurance carriers to identify providers.

Round Table Discussion

Round Table Discussion

• Steven K. Young, CSA – Washington

• Michael Orstead, CSA - Virginia

• Debbie Ivory, CSA - Virginia

• Kathleen Duffy, CSA - Florida

• Luis F. Aragon, CSA - Illinois

NSAA 2014 conference

Healthcare

Transcript of NSAA 2014 conference