Re: Pay at time of Service for Covered CPT --> Re: Flu...

[Guest guest]

If a patietn with a hsa high dedcutible pays you with a cash discount and they never submit it to their  deductible, essentially saying why bother to get a 23.00 charge applied on dec 29 to my 5,000 high dedcutible,  becasue the choice is to submit it for them and them the get a 23.00   bill  later not a discounted say 18.00  bill,  how is that illegal?

AS long as I offer the cash pay discount the same way and  same price  to everyone  ( excepting medicare which would make no sense/doesn;t apply( although if someone had medicare and you knew it and they tried to pay you cash  which would be bizarre  then  I suppose it si trouble, but  it is never to their advantage so  why muddle the waters about that,   but medicaid patients now they   will offer this to get in  sooner  " I will just pay you " and that is illegal you have to take their mediciad if you know they have it yes?),

 then I can offer  a prompt pay cash discount to anyone. BUt was that the  question? I am still on   iFNBT and didn'tget to read about dementia yet sigh.

 

Deanna,

It absolutely violates contract provisions.  It just they

don’t have the means to police all of this.  So you have to decide

to play by the rules?  Or not and bank on the fact that you won’t

get caught.

 

What fee goes to deductible – the “usual” or

the “prompt pay fee”. 

 

 

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

 

 

 

From:

[mailto: ] On Behalf Of tolpeople@...

Sent: Friday, February 25, 2011 9:39 PM

To:

Subject: Re: Pay at time of Service for Covered CPT --> Re:

Flu...

 

 

,

 

Apparently, Medicare and other insurers do not care if you do not

submit bills to them and the patients pay out-of-pocket for these services,

because the retail clinics, which book many thousands of visits each year, are

not having any trouble with this.

 

Patients who have insurance generally use their insurance, if the

service is a covered benefit, and pay their regular OV copay.  Until this

last year, many companies did not cover flu shots (usually decided when the

employer purchases the insurance), so patients just paid out-of-pocket for

them.  After January 1st, that has changed, since it is part of the

Affordable Care Act that all insurance carriers must provide all preventive

care (per the national guidelines) at 100% with no copay and no

deductible.  However, many of the patrons of the retail clinics (and my

practice) do not have any health insurance, and so they pay the prompt-pay

rate.  For instance, The Little Clinic (inside some King Soopers/Krogers

grocery stores) charges $29 for a sports physical, $69 for an office visit,

etc.  This is substantially less than people would pay for these services

at most physician's offices. 

 

If a patient has a high-deductible insurance policy, many will

choose to use the prompt-pay rate, since their insurance would pay nothing

until they reached $2500, or $10,000, dollars.  They collect the receipts

until they meet the deductible, then submit them.  We've had no trouble

with Medicare, or any other insurance, over these practices, either. 

 

Not sure why this doesn't violate the contract provisions -- but

if it does, no one seems to care.

 

Deanna

 

 

In a message dated 2/25/2011 4:53:14 P.M. Mountain Standard Time,

lockecolorado@... writes:

 

Thanks, Deanna,

We've had this discussion on the list in the past.

It is OK to give a prompt pay discount - the argument being that

you would give private insurances the same prompt pay discount if they paid at

time of service.

The 2 concerns that were brought up in the past are...

 

1. If your prompt pay discount is less than what you give to

insurances and/or the discount is less than Medicare and you have a significant

amount of cash pay patients - insurance may argue that your usual and customary

payment is actually the discount and not the higher amount you charge the

insurance.

 

2. I was not arguing this Prompt Pay Discount point - I was

arguing the issue that doing cash pay is fine, but contractually, you must

submit the bill to the patient's insurance - unless it is something known

to not be covered (ie acupuncture and Medicare). So if the patient has

insurance, the flu shots are probably a covered benefit and so you need to

submit the charge to that insurance. Also, even though you may be giving a

discount - perhaps some insurances allow even less than the cash discount

- and the patient would have been charged less than the amount of the discount

if the charge had been submitted to insurance - that is where I think one could

get into trouble with insurances.

 

That's the point I was trying (unsuccessfully) to make.

 

Thanks

 

Locke, MD

 

On Fri, Feb 25, 2011 at 3:42 PM,

wrote:

 

,

 

Having worked now in retail care

for a couple of years (those clinics staffed by NPs inside stores), I think I

know the answer to this question.  These clinics offer a set of services for

a cash-pay price -- for instance, $29 for a sports physical, $25 for a flu

shot, etc.  These are advertised on their web site, on a television at the

front of the clinic, and are quoted to patients at the desk and over the phone.

 

The clinic also bills most

commercial insurers, Medicare, and TriCare.  Medicaid won't contract with

some of these clinics because they don't meet all the Medicaid

requirements.  Medicare allows these cash-pay, on-the-same-day discounted

fees to stand because the patient is paying at the time of service.  It is

called a " prompt-pay discount. "   It cannot be paid at a later

date or billed in any way. Credit card, cash, or check must be collected at the

time of the visit.

 

Medicare allows this because it

assumes the provider does not have the cost of billing added to the fee -- and

that includes all the costs of billing.  The prompt-pay fees must be the

same for everyone, so I can't charge one person $25 and another person $15 for

a flu shot, unless I have changed the price for everyone. 

 

I can't quote you the chapter and

verse in the Medicare documentation, but I know it exists or all these retail

clinics would be committing Medicare fraud -- and I'm sure their lawyers have

already figured out where the chapter and verse are. 

 

Hope that helps, and hope I'm

right.

 

Deanna

 

In a message dated 2/25/2011

2:05:15 A.M. Mountain Standard Time, lockecolorado@...

writes:

 

Deanna,

I think many practices do what

you mention below, but I've always wondered about the legality of it -- or at

least the contractuality of it.

 

My understanding has always been

- if a service is covered by insurance and we are contracted with that

insurance - we can't just take cash and not bill the insurance.

 

One can probably get in trouble

coming and going.

If I charge $100 for a CPT code

to insurance, but insurance pays $80 and I allow the patient to have it for $50

-- the insurance is going to wonder why they don't get it for $50 - since it is

below what they allow.

Converseley, if you charge $100

and the insurance pays $80, but you give a " discount " to the patient

of 10%, so they only pay $90 -- the insurance (and probably the patient) is

going to say that you can't do that because the allowed from the insurance

would have been $80 - so you overcharged the patient.

 

Anyway, that has always been my

take on it.

If the insurance pays for a CPT

code - I can never just take cash - I have to submit the bill.

 

But I could be wrong.

 

Anyone have experience with this

issue?

 

Locke, MD

On Mon, Dec 13, 2010 at 2:25 PM,

wrote:

 

I have about 70 doses left. 

Any idea about how to advertise this without spending much money?  I've

lowered my price to $15 (pay at the time of visit).  Hate to see this go

to waste -- and would like to cover my vaccine bill!

 

Deanna, FNP

 

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[Guest guest]

I'm not making my case very effectively, but...in the situation you are describing, the issue isn't with the patient, but with you and our contract with the patient's insurance company.

Unless you are charging the patient exactly what the insurance allows, you are probably outside your contract with the insurance.

If you charge $23 and give the patient a discount to $18 - unless the insurance allowed is exactly $18, you are over or undercharging the patient based on your contract with the insurance company.

Even if they have an HSA and would have to pay for all the bill anyway - the patient should only have to pay for the amount allowed by the insurance company.

If you are charging less than the allowed by the insurance -- it's probably not a big deal once or twice -- but if you do it consistently, the insurance company may want to have this lower amount as your standard fee they will pay.

Anyway, that's my take on it.

Locke, MD

 

If a patietn with a hsa high dedcutible pays you with a cash disc ount and they never submit it to their  deductible, essentially saying why bother to get a 23.00 charge applied on dec 29 to my 5,000 high dedcutible,  becasue the choice is to submit it for them and them the get a 23.00   bill  later not a discounted say 18.00  bill,  how is that illegal?

AS long as I offer the cash pay discount the same way and  same price  to everyone  ( excepting medicare which would make no sense/doesn;t apply( although if someone had medicare and you knew it and they tried to pay you cash  which would be bizarre  then  I suppose it si trouble, but  it is never to their advantage so  why muddle the waters about that,   but medicaid patients now they   will offer this to get in  sooner  " I will just pay you " and that is illegal you have to take their mediciad if you know they have it yes?),

 then I can offer  a prompt pay cash discount to anyone. BUt was that the  question? I am still on   iFNBT and didn'tget to read about dementia yet sigh.

 

Deanna,

It absolutely violates contract provisions.  It just they don’t have the means to police all of this.  So you have to decide to play by the rules?  Or not and bank on the fact that you won’t get caught.

 

What fee goes to deductible – the “usual” or the “prompt pay fee”. 

 

 

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

 

 

 

From: [mailto: ] On Behalf Of tolpeople@...

Sent: Friday, February 25, 2011 9:39 PMTo: Subject: Re: Pay at time of Service for Covered CPT --> Re: Flu...

 

 

,

 

Apparently, Medicare and other insurers do not care if you do not submit bills to them and the patients pay out-of-pocket for these services, because the retail clinics, which book many thousands of visits each year, are not having any trouble with this.

 

Patients who have insurance generally use their insurance, if the service is a covered benefit, and pay their regular OV copay.  Until this last year, many companies did not cover flu shots (usually decided when the employer purchases the insurance), so patients just paid out-of-pocket for them.  After January 1st, that has changed, since it is part of the Affordable Care Act that all insurance carriers must provide all preventive care (per the national guidelines) at 100% with no copay and no deductible.  However, many of the patrons of the retail clinics (and my practice) do not have any health insurance, and so they pay the prompt-pay rate.  For instance, The Little Clinic (inside some King Soopers/Krogers grocery stores) charges $29 for a sports physical, $69 for an office visit, etc.  This is substantially less than people would pay for these services at most physician's offices. 

 

If a patient has a high-deductible insurance policy, many will choose to use the prompt-pay rate, since their insurance would pay nothing until they reached $2500, or $10,000, dollars.  They collect the receipts until they meet the deductible, then submit them.  We've had no trouble with Medicare, or any other insurance, over these practices, either. 

 

Not sure why this doesn't violate the contract provisions -- but if it does, no one seems to care.

 

Deanna

 

 

 

Thanks, Deanna,

We've had this discussion on the list in the past.

It is OK to give a prompt pay discount - the argument being that you would give private insurances the same prompt pay discount if they paid at time of service.

The 2 concerns that were brought up in the past are...

 

1. If your prompt pay discount is less than what you give to insurances and/or the discount is less than Medicare and you have a significant amount of cash pay patients - insurance may argue that your usual and customary payment is actually the discount and not the higher amount you charge the insurance.

 

2. I was not arguing this Prompt Pay Discount point - I was arguing the issue that doing cash pay is fine, but contractually, you must submit the bill to the patient's insurance - unless it is something known to not be covered (ie acupuncture and Medicare). So if the patient has insurance, the flu shots are probably a covered benefit and so you need to submit the charge to that insurance. Also, even though you may be giving a discount - perhaps some insurances allow even less than the cash discount - and the patient would have been charged less than the amount of the discount if the charge had been submitted to insurance - that is where I think one could get into trouble with insurances.

 

That's the point I was trying (unsuccessfully) to make.

 

Thanks

 

Locke, MD

 

 

,

 

Having worked now in retail care for a couple of years (those clinics staffed by NPs inside stores), I think I know the answer to this question.  These clinics offer a set of services for a cash-pay price -- for instance, $29 for a sports physical, $25 for a flu shot, etc.  These are advertised on their web site, on a television at the front of the clinic, and are quoted to patients at the desk and over the phone.

 

The clinic also bills most commercial insurers, Medicare, and TriCare.  Medicaid won't contract with some of these clinics because they don't meet all the Medicaid requirements.  Medicare allows these cash-pay, on-the-same-day discounted fees to stand because the patient is paying at the time of service.  It is called a " prompt-pay discount. "   It cannot be paid at a later date or billed in any way. Credit card, cash, or check must be collected at the time of the visit.

 

Medicare allows this because it assumes the provider does not have the cost of billing added to the fee -- and that includes all the costs of billing.  The prompt-pay fees must be the same for everyone, so I can't charge one person $25 and another person $15 for a flu shot, unless I have changed the price for everyone. 

 

I can't quote you the chapter and verse in the Medicare documentation, but I know it exists or all these retail clinics would be committing Medicare fraud -- and I'm sure their lawyers have already figured out where the chapter and verse are. 

 

Hope that helps, and hope I'm right.

 

Deanna

 

 

Deanna,

I think many practices do what you mention below, but I've always wondered about the legality of it -- or at least the contractuality of it.

 

My understanding has always been - if a service is covered by insurance and we are contracted with that insurance - we can't just take cash and not bill the insurance.

 

One can probably get in trouble coming and going.

If I charge $100 for a CPT code to insurance, but insurance pays $80 and I allow the patient to have it for $50 -- the insurance is going to wonder why they don't get it for $50 - since it is below what they allow.

Converseley, if you charge $100 and the insurance pays $80, but you give a " discount " to the patient of 10%, so they only pay $90 -- the insurance (and probably the patient) is going to say that you can't do that because the allowed from the insurance would have been $80 - so you overcharged the patient.

 

Anyway, that has always been my take on it.

If the insurance pays for a CPT code - I can never just take cash - I have to submit the bill.

 

But I could be wrong.

 

Anyone have experience with this issue?

 

Locke, MD

 

I have about 70 doses left.  Any idea about how to advertise this without spending much money?  I've lowered my price to $15 (pay at the time of visit).  Hate to see this go to waste -- and would like to cover my vaccine bill!

 

Deanna, FNP

 

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impcenter.org

[Guest guest]

I agree with , that is my take also and what I have always been told. It's contract law. You can't legally charge the patient less than you would have charged the insurance company if they were footing the bill. Part of our contract with the insurance company. If you con't participate, then great, no worries.

Kathy Saradarian

Re: Pay at time of Service for Covered CPT --> Re: Flu...

I'm not making my case very effectively, but...in the situation you are describing, the issue isn't with the patient, but with you and our contract with the patient's insurance company.

Unless you are charging the patient exactly what the insurance allows, you are probably outside your contract with the insurance.

If you charge $23 and give the patient a discount to $18 - unless the insurance allowed is exactly $18, you are over or undercharging the patient based on your contract with the insurance company.

Even if they have an HSA and would have to pay for all the bill anyway - the patient should only have to pay for the amount allowed by the insurance company.

If you are charging less than the allowed by the insurance -- it's probably not a big deal once or twice -- but if you do it consistently, the insurance company may want to have this lower amount as your standard fee they will pay.

Anyway, that's my take on it.

Locke, MD

If a patietn with a hsa high dedcutible pays you with a cash disc ount and they never submit it to their deductible, essentially saying why bother to get a 23.00 charge applied on dec 29 to my 5,000 high dedcutible, becasue the choice is to submit it for them and them the get a 23.00 bill later not a discounted say 18.00 bill, how is that illegal?AS long as I offer the cash pay discount the same way and same price to everyone ( excepting medicare which would make no sense/doesn;t apply( although if someone had medicare and you knew it and they tried to pay you cash which would be bizarre then I suppose it si trouble, but it is never to their advantage so why muddle the waters about that, but medicaid patients now they will offer this to get in sooner "I will just pay you" and that is illegal you have to take their mediciad if you know they have it yes?), then I can offer a prompt pay cash discount to anyone. BUt was that the question? I am still on iFNBT and didn'tget to read about dementia yet sigh.

Deanna,

It absolutely violates contract provisions. It just they don’t have the means to police all of this. So you have to decide to play by the rules? Or not and bank on the fact that you won’t get caught.

What fee goes to deductible – the “usual†or the “prompt pay feeâ€.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From: [mailto: ] On Behalf Of tolpeople@...Sent: Friday, February 25, 2011 9:39 PMTo: Subject: Re: Pay at time of Service for Covered CPT --> Re: Flu...

,

Apparently, Medicare and other insurers do not care if you do not submit bills to them and the patients pay out-of-pocket for these services, because the retail clinics, which book many thousands of visits each year, are not having any trouble with this.

Patients who have insurance generally use their insurance, if the service is a covered benefit, and pay their regular OV copay. Until this last year, many companies did not cover flu shots (usually decided when the employer purchases the insurance), so patients just paid out-of-pocket for them. After January 1st, that has changed, since it is part of the Affordable Care Act that all insurance carriers must provide all preventive care (per the national guidelines) at 100% with no copay and no deductible. However, many of the patrons of the retail clinics (and my practice) do not have any health insurance, and so they pay the prompt-pay rate. For instance, The Little Clinic (inside some King Soopers/Krogers grocery stores) charges $29 for a sports physical, $69 for an office visit, etc. This is substantially less than people would pay for these services at most physician's offices.

If a patient has a high-deductible insurance policy, many will choose to use the prompt-pay rate, since their insurance would pay nothing until they reached $2500, or $10,000, dollars. They collect the receipts until they meet the deductible, then submit them. We've had no trouble with Medicare, or any other insurance, over these practices, either.

Not sure why this doesn't violate the contract provisions -- but if it does, no one seems to care.

Deanna

Thanks, Deanna,

We've had this discussion on the list in the past.

It is OK to give a prompt pay discount - the argument being that you would give private insurances the same prompt pay discount if they paid at time of service.

The 2 concerns that were brought up in the past are...

1. If your prompt pay discount is less than what you give to insurances and/or the discount is less than Medicare and you have a significant amount of cash pay patients - insurance may argue that your usual and customary payment is actually the discount and not the higher amount you charge the insurance.

2. I was not arguing this Prompt Pay Discount point - I was arguing the issue that doing cash pay is fine, but contractually, you must submit the bill to the patient's insurance - unless it is something known to not be covered (ie acupuncture and Medicare). So if the patient has insurance, the flu shots are probably a covered benefit and so you need to submit the charge to that insurance. Also, even though you may be giving a discount - perhaps some insurances allow even less than the cash discount - and the patient would have been charged less than the amount of the discount if the charge had been submitted to insurance - that is where I think one could get into trouble with insurances.

That's the point I was trying (unsuccessfully) to make.

Thanks

Locke, MD

,

Having worked now in retail care for a couple of years (those clinics staffed by NPs inside stores), I think I know the answer to this question. These clinics offer a set of services for a cash-pay price -- for instance, $29 for a sports physical, $25 for a flu shot, etc. These are advertised on their web site, on a television at the front of the clinic, and are quoted to patients at the desk and over the phone.

The clinic also bills most commercial insurers, Medicare, and TriCare. Medicaid won't contract with some of these clinics because they don't meet all the Medicaid requirements. Medicare allows these cash-pay, on-the-same-day discounted fees to stand because the patient is paying at the time of service. It is called a "prompt-pay discount." It cannot be paid at a later date or billed in any way. Credit card, cash, or check must be collected at the time of the visit.

Medicare allows this because it assumes the provider does not have the cost of billing added to the fee -- and that includes all the costs of billing. The prompt-pay fees must be the same for everyone, so I can't charge one person $25 and another person $15 for a flu shot, unless I have changed the price for everyone.

I can't quote you the chapter and verse in the Medicare documentation, but I know it exists or all these retail clinics would be committing Medicare fraud -- and I'm sure their lawyers have already figured out where the chapter and verse are.

Hope that helps, and hope I'm right.

Deanna

Deanna,

I think many practices do what you mention below, but I've always wondered about the legality of it -- or at least the contractuality of it.

My understanding has always been - if a service is covered by insurance and we are contracted with that insurance - we can't just take cash and not bill the insurance.

One can probably get in trouble coming and going.

If I charge $100 for a CPT code to insurance, but insurance pays $80 and I allow the patient to have it for $50 -- the insurance is going to wonder why they don't get it for $50 - since it is below what they allow.

Converseley, if you charge $100 and the insurance pays $80, but you give a "discount" to the patient of 10%, so they only pay $90 -- the insurance (and probably the patient) is going to say that you can't do that because the allowed from the insurance would have been $80 - so you overcharged the patient.

Anyway, that has always been my take on it.

If the insurance pays for a CPT code - I can never just take cash - I have to submit the bill.

But I could be wrong.

Anyone have experience with this issue?

Locke, MD

I have about 70 doses left. Any idea about how to advertise this without spending much money? I've lowered my price to $15 (pay at the time of visit). Hate to see this go to waste -- and would like to cover my vaccine bill!

Deanna, FNP

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[Guest guest]

However, if the discount is for payment at the time of service(PTOS), that you would also offer to the insurance company if they were willing to PTOS, then you are likely within your contract. But of course, all contracts may vary and we all should carefully read our contracts. I spoke with my state BCBS fraud person about this and he stated that if the patient did not want to use their insurance for a visit in order to take advantage of such a discount, it was up to them and I was not doing anything wrong. What he did not answer was what happens when that patient wants a claim form to send in later. I think that is when it really gets sticky. I'm lucky in that my BCBS folks are generally helpful. I've called the bigwigs at my other two major payors with good

results also. Perhaps the advantage of a state with a low population.Now, back to PTOS... perhaps the insurance companies should provide their beneficiaries with a debit card and us with a terminal... we run their card at the end of the visit, input diagnosis codes/charges and the system recognizes us, calculates the payment details and deposits it in our bank. Then the insurer could get the PTOS discount with a smile from me.CarlaTo: Sent: Sat, February 26, 2011 10:11:22 AMSubject: Re: Pay at time of Service for Covered CPT --> Re: Flu...

I'm not making my case very effectively, but...in the situation you are describing, the issue isn't with the patient, but with you and our contract with the patient's insurance company.

Unless you are charging the patient exactly what the insurance allows, you are probably outside your contract with the insurance.

If you charge $23 and give the patient a discount to $18 - unless the insurance allowed is exactly $18, you are over or undercharging the patient based on your contract with the insurance company.

Even if they have an HSA and would have to pay for all the bill anyway - the patient should only have to pay for the amount allowed by the insurance company.

If you are charging less than the allowed by the insurance -- it's probably not a big deal once or twice -- but if you do it consistently, the insurance company may want to have this lower amount as your standard fee they will pay.

Anyway, that's my take on it.

Locke, MD

If a patietn with a hsa high dedcutible pays you with a cash disc ount and they never submit it to their deductible, essentially saying why bother to get a 23.00 charge applied on dec 29 to my 5,000 high dedcutible, becasue the choice is to submit it for them and them the get a 23.00 bill later not a discounted say 18.00 bill, how is that illegal?

AS long as I offer the cash pay discount the same way and same price to everyone ( excepting medicare which would make no sense/doesn;t apply( although if someone had medicare and you knew it and they tried to pay you cash which would be bizarre then I suppose it si trouble, but it is never to their advantage so why muddle the waters about that, but medicaid patients now they will offer this to get in sooner "I will just pay you" and that is illegal you have to take their mediciad if you know they have it yes?),

then I can offer a prompt pay cash discount to anyone. BUt was that the question? I am still on iFNBT and didn'tget to read about dementia yet sigh.

Deanna,

It absolutely violates contract provisions. It just they don’t have the means to police all of this. So you have to decide to play by the rules? Or not and bank on the fact that you won’t get caught.

What fee goes to deductible – the “usual†or the “prompt pay feeâ€.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From: [mailto: ] On Behalf Of tolpeople@...

Sent: Friday, February 25, 2011 9:39 PMTo: Subject: Re: Pay at time of Service for Covered CPT --> Re: Flu...

,

Apparently, Medicare and other insurers do not care if you do not submit bills to them and the patients pay out-of-pocket for these services, because the retail clinics, which book many thousands of visits each year, are not having any trouble with this.

Patients who have insurance generally use their insurance, if the service is a covered benefit, and pay their regular OV copay. Until this last year, many companies did not cover flu shots (usually decided when the employer purchases the insurance), so patients just paid out-of-pocket for them. After January 1st, that has changed, since it is part of the Affordable Care Act that all insurance carriers must provide all preventive care (per the national guidelines) at 100% with no copay and no deductible. However, many of the patrons of the retail clinics (and my practice) do not have any health insurance, and so they pay the prompt-pay rate. For instance, The Little Clinic (inside some King Soopers/Krogers grocery stores) charges $29 for a sports physical, $69 for an office visit, etc. This is substantially less than people would pay for these services at most

physician's offices.

If a patient has a high-deductible insurance policy, many will choose to use the prompt-pay rate, since their insurance would pay nothing until they reached $2500, or $10,000, dollars. They collect the receipts until they meet the deductible, then submit them. We've had no trouble with Medicare, or any other insurance, over these practices, either.

Not sure why this doesn't violate the contract provisions -- but if it does, no one seems to care.

Deanna

Thanks, Deanna,

We've had this discussion on the list in the past.

It is OK to give a prompt pay discount - the argument being that you would give private insurances the same prompt pay discount if they paid at time of service.

The 2 concerns that were brought up in the past are...

1. If your prompt pay discount is less than what you give to insurances and/or the discount is less than Medicare and you have a significant amount of cash pay patients - insurance may argue that your usual and customary payment is actually the discount and not the higher amount you charge the insurance.

2. I was not arguing this Prompt Pay Discount point - I was arguing the issue that doing cash pay is fine, but contractually, you must submit the bill to the patient's insurance - unless it is something known to not be covered (ie acupuncture and Medicare). So if the patient has insurance, the flu shots are probably a covered benefit and so you need to submit the charge to that insurance. Also, even though you may be giving a discount - perhaps some insurances allow even less than the cash discount - and the patient would have been charged less than the amount of the discount if the charge had been submitted to insurance - that is where I think one could get into trouble with insurances.

That's the point I was trying (unsuccessfully) to make.

Thanks

Locke, MD

,

Having worked now in retail care for a couple of years (those clinics staffed by NPs inside stores), I think I know the answer to this question. These clinics offer a set of services for a cash-pay price -- for instance, $29 for a sports physical, $25 for a flu shot, etc. These are advertised on their web site, on a television at the front of the clinic, and are quoted to patients at the desk and over the phone.

The clinic also bills most commercial insurers, Medicare, and TriCare. Medicaid won't contract with some of these clinics because they don't meet all the Medicaid requirements. Medicare allows these cash-pay, on-the-same-day discounted fees to stand because the patient is paying at the time of service. It is called a "prompt-pay discount." It cannot be paid at a later date or billed in any way. Credit card, cash, or check must be collected at the time of the visit.

Medicare allows this because it assumes the provider does not have the cost of billing added to the fee -- and that includes all the costs of billing. The prompt-pay fees must be the same for everyone, so I can't charge one person $25 and another person $15 for a flu shot, unless I have changed the price for everyone.

I can't quote you the chapter and verse in the Medicare documentation, but I know it exists or all these retail clinics would be committing Medicare fraud -- and I'm sure their lawyers have already figured out where the chapter and verse are.

Hope that helps, and hope I'm right.

Deanna

Deanna,

I think many practices do what you mention below, but I've always wondered about the legality of it -- or at least the contractuality of it.

My understanding has always been - if a service is covered by insurance and we are contracted with that insurance - we can't just take cash and not bill the insurance.

One can probably get in trouble coming and going.

If I charge $100 for a CPT code to insurance, but insurance pays $80 and I allow the patient to have it for $50 -- the insurance is going to wonder why they don't get it for $50 - since it is below what they allow.

Converseley, if you charge $100 and the insurance pays $80, but you give a "discount" to the patient of 10%, so they only pay $90 -- the insurance (and probably the patient) is going to say that you can't do that because the allowed from the insurance would have been $80 - so you overcharged the patient.

Anyway, that has always been my take on it.

If the insurance pays for a CPT code - I can never just take cash - I have to submit the bill.

But I could be wrong.

Anyone have experience with this issue?

Locke, MD

I have about 70 doses left. Any idea about how to advertise this without spending much money? I've lowered my price to $15 (pay at the time of visit). Hate to see this go to waste -- and would like to cover my vaccine bill!

Deanna, FNP

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[Guest guest]

 Kathy and - you guys are right exactly of course  I got some muddled in saying one thing and   thinking another  I think   Sorry I  confused anyone Besides myslef  I am steppeding away from the SEND button now

 

I agree with , that is my take also and what I have always been told.  It's contract law.  You can't legally charge the patient less than you would have charged the insurance company if they were footing the bill.  Part of our contract with the insurance company.  If you con't participate, then great, no worries.

 

Kathy Saradarian

Re: Pay at time of Service for Covered CPT --> Re: Flu... 

I'm not making my case very effectively, but...in the situation you are describing, the issue isn't with the patient, but with you and our contract with the patient's insurance company.

Unless you are charging the patient exactly what the insurance allows, you are probably outside your contract with the insurance.

If you charge $23 and give the patient a discount to $18 - unless the insurance allowed is exactly $18, you are over or undercharging the patient based on your contract with the insurance company.

Even if they have an HSA and would have to pay for all the bill anyway - the patient should only have to pay for the amount allowed by the insurance company.

If you are charging less than the allowed by the insurance -- it's probably not a big deal once or twice -- but if you do it consistently, the insurance company may want to have this lower amount as your standard fee they will pay.

Anyway, that's my take on it.

Locke, MD

 

If a patietn with a hsa high dedcutible pays you with a cash disc ount and they never submit it to their  deductible, essentially saying why bother to get a 23.00 charge applied on dec 29 to my 5,000 high dedcutible,  becasue the choice is to submit it for them and them the get a 23.00   bill  later not a discounted say 18.00  bill,  how is that illegal?

AS long as I offer the cash pay discount the same way and  same price  to everyone  ( excepting medicare which would make no sense/doesn;t apply( although if someone had medicare and you knew it and they tried to pay you cash  which would be bizarre  then  I suppose it si trouble, but  it is never to their advantage so  why muddle the waters about that,   but medicaid patients now they   will offer this to get in  sooner  " I will just pay you " and that is illegal you have to take their mediciad if you know they have it yes?),

 then I can offer  a prompt pay cash discount to anyone. BUt was that the  question? I am still on   iFNBT and didn'tget to read about dementia yet sigh.

 

Deanna,

It absolutely violates contract provisions.  It just they don’t have the means to police all of this.  So you have to decide to play by the rules?  Or not and bank on the fact that you won’t get caught.

 

What fee goes to deductible – the “usual” or the “prompt pay fee”. 

 

 

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

 

 

 

From: [mailto: ] On Behalf Of tolpeople@...

Sent: Friday, February 25, 2011 9:39 PMTo: Subject: Re: Pay at time of Service for Covered CPT --> Re: Flu...

 

,

 

Apparently, Medicare and other insurers do not care if you do not submit bills to them and the patients pay out-of-pocket for these services, because the retail clinics, which book many thousands of visits each year, are not having any trouble with this.

 

Patients who have insurance generally use their insurance, if the service is a covered benefit, and pay their regular OV copay.  Until this last year, many companies did not cover flu shots (usually decided when the employer purchases the insurance), so patients just paid out-of-pocket for them.  After January 1st, that has changed, since it is part of the Affordable Care Act that all insurance carriers must provide all preventive care (per the national guidelines) at 100% with no copay and no deductible.  However, many of the patrons of the retail clinics (and my practice) do not have any health insurance, and so they pay the prompt-pay rate.  For instance, The Little Clinic (inside some King Soopers/Krogers grocery stores) charges $29 for a sports physical, $69 for an office visit, etc.  This is substantially less than people would pay for these services at most physician's offices. 

 

If a patient has a high-deductible insurance policy, many will choose to use the prompt-pay rate, since their insurance would pay nothing until they reached $2500, or $10,000, dollars.  They collect the receipts until they meet the deductible, then submit them.  We've had no trouble with Medicare, or any other insurance, over these practices, either. 

 

Not sure why this doesn't violate the contract provisions -- but if it does, no one seems to care.

 

Deanna

 

 

 

Thanks, Deanna,

We've had this discussion on the list in the past.

It is OK to give a prompt pay discount - the argument being that you would give private insurances the same prompt pay discount if they paid at time of service.

The 2 concerns that were brought up in the past are...

 

1. If your prompt pay discount is less than what you give to insurances and/or the discount is less than Medicare and you have a significant amount of cash pay patients - insurance may argue that your usual and customary payment is actually the discount and not the higher amount you charge the insurance.

 

2. I was not arguing this Prompt Pay Discount point - I was arguing the issue that doing cash pay is fine, but contractually, you must submit the bill to the patient's insurance - unless it is something known to not be covered (ie acupuncture and Medicare). So if the patient has insurance, the flu shots are probably a covered benefit and so you need to submit the charge to that insurance. Also, even though you may be giving a discount - perhaps some insurances allow even less than the cash discount - and the patient would have been charged less than the amount of the discount if the charge had been submitted to insurance - that is where I think one could get into trouble with insurances.

 

That's the point I was trying (unsuccessfully) to make.

 

Thanks

 

Locke, MD

 

 

,

 

Having worked now in retail care for a couple of years (those clinics staffed by NPs inside stores), I think I know the answer to this question.  These clinics offer a set of services for a cash-pay price -- for instance, $29 for a sports physical, $25 for a flu shot, etc.  These are advertised on their web site, on a television at the front of the clinic, and are quoted to patients at the desk and over the phone.

 

The clinic also bills most commercial insurers, Medicare, and TriCare.  Medicaid won't contract with some of these clinics because they don't meet all the Medicaid requirements.  Medicare allows these cash-pay, on-the-same-day discounted fees to stand because the patient is paying at the time of service.  It is called a " prompt-pay discount. "   It cannot be paid at a later date or billed in any way. Credit card, cash, or check must be collected at the time of the visit.

 

Medicare allows this because it assumes the provider does not have the cost of billing added to the fee -- and that includes all the costs of billing.  The prompt-pay fees must be the same for everyone, so I can't charge one person $25 and another person $15 for a flu shot, unless I have changed the price for everyone. 

 

I can't quote you the chapter and verse in the Medicare documentation, but I know it exists or all these retail clinics would be committing Medicare fraud -- and I'm sure their lawyers have already figured out where the chapter and verse are. 

 

Hope that helps, and hope I'm right.

 

Deanna

 

 

Deanna,

I think many practices do what you mention below, but I've always wondered about the legality of it -- or at least the contractuality of it.

 

My understanding has always been - if a service is covered by insurance and we are contracted with that insurance - we can't just take cash and not bill the insurance.

 

One can probably get in trouble coming and going.

If I charge $100 for a CPT code to insurance, but insurance pays $80 and I allow the patient to have it for $50 -- the insurance is going to wonder why they don't get it for $50 - since it is below what they allow.

Converseley, if you charge $100 and the insurance pays $80, but you give a " discount " to the patient of 10%, so they only pay $90 -- the insurance (and probably the patient) is going to say that you can't do that because the allowed from the insurance would have been $80 - so you overcharged the patient.

 

Anyway, that has always been my take on it.

If the insurance pays for a CPT code - I can never just take cash - I have to submit the bill.

 

But I could be wrong.

 

Anyone have experience with this issue?

 

Locke, MD

 

I have about 70 doses left.  Any idea about how to advertise this without spending much money?  I've lowered my price to $15 (pay at the time of visit).  Hate to see this go to waste -- and would like to cover my vaccine bill!

 

Deanna, FNP

 

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ph    fax impcenter.org

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[Guest guest]

This not discounting below Medicare happens in California with every private insurer. They can do it but not us. They pay us all different amts too. But we can do that w our pts. Double standards. I like the idea of an immediate pay debt card Sent from my iPhone

However, if the discount is for payment at the time of service(PTOS), that you would also offer to the insurance company if they were willing to PTOS, then you are likely within your contract. But of course, all contracts may vary and we all should carefully read our contracts. I spoke with my state BCBS fraud person about this and he stated that if the patient did not want to use their insurance for a visit in order to take advantage of such a discount, it was up to them and I was not doing anything wrong. What he did not answer was what happens when that patient wants a claim form to send in later. I think that is when it really gets sticky. I'm lucky in that my BCBS folks are generally helpful. I've called the bigwigs at my other two major payors with good

results also. Perhaps the advantage of a state with a low population.Now, back to PTOS... perhaps the insurance companies should provide their beneficiaries with a debit card and us with a terminal... we run their card at the end of the visit, input diagnosis codes/charges and the system recognizes us, calculates the payment details and deposits it in our bank. Then the insurer could get the PTOS discount with a smile from me.CarlaTo: Sent: Sat, February 26, 2011 10:11:22 AMSubject: Re: Pay at time of Service for Covered CPT --> Re: Flu...

I'm not making my case very effectively, but...in the situation you are describing, the issue isn't with the patient, but with you and our contract with the patient's insurance company.

Unless you are charging the patient exactly what the insurance allows, you are probably outside your contract with the insurance.

If you charge $23 and give the patient a discount to $18 - unless the insurance allowed is exactly $18, you are over or undercharging the patient based on your contract with the insurance company.

Even if they have an HSA and would have to pay for all the bill anyway - the patient should only have to pay for the amount allowed by the insurance company.

If you are charging less than the allowed by the insurance -- it's probably not a big deal once or twice -- but if you do it consistently, the insurance company may want to have this lower amount as your standard fee they will pay.

Anyway, that's my take on it.

Locke, MD

If a patietn with a hsa high dedcutible pays you with a cash disc ount and they never submit it to their deductible, essentially saying why bother to get a 23.00 charge applied on dec 29 to my 5,000 high dedcutible, becasue the choice is to submit it for them and them the get a 23.00 bill later not a discounted say 18.00 bill, how is that illegal?

AS long as I offer the cash pay discount the same way and same price to everyone ( excepting medicare which would make no sense/doesn;t apply( although if someone had medicare and you knew it and they tried to pay you cash which would be bizarre then I suppose it si trouble, but it is never to their advantage so why muddle the waters about that, but medicaid patients now they will offer this to get in sooner "I will just pay you" and that is illegal you have to take their mediciad if you know they have it yes?),

then I can offer a prompt pay cash discount to anyone. BUt was that the question? I am still on iFNBT and didn'tget to read about dementia yet sigh.

Deanna,

It absolutely violates contract provisions. It just they don’t have the means to police all of this. So you have to decide to play by the rules? Or not and bank on the fact that you won’t get caught.

What fee goes to deductible – the “usual†or the “prompt pay feeâ€.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From: [mailto: ] On Behalf Of tolpeople@...

Sent: Friday, February 25, 2011 9:39 PMTo: Subject: Re: Pay at time of Service for Covered CPT --> Re: Flu...

,

Apparently, Medicare and other insurers do not care if you do not submit bills to them and the patients pay out-of-pocket for these services, because the retail clinics, which book many thousands of visits each year, are not having any trouble with this.

Patients who have insurance generally use their insurance, if the service is a covered benefit, and pay their regular OV copay. Until this last year, many companies did not cover flu shots (usually decided when the employer purchases the insurance), so patients just paid out-of-pocket for them. After January 1st, that has changed, since it is part of the Affordable Care Act that all insurance carriers must provide all preventive care (per the national guidelines) at 100% with no copay and no deductible. However, many of the patrons of the retail clinics (and my practice) do not have any health insurance, and so they pay the prompt-pay rate. For instance, The Little Clinic (inside some King Soopers/Krogers grocery stores) charges $29 for a sports physical, $69 for an office visit, etc. This is substantially less than people would pay for these services at most

physician's offices.

If a patient has a high-deductible insurance policy, many will choose to use the prompt-pay rate, since their insurance would pay nothing until they reached $2500, or $10,000, dollars. They collect the receipts until they meet the deductible, then submit them. We've had no trouble with Medicare, or any other insurance, over these practices, either.

Not sure why this doesn't violate the contract provisions -- but if it does, no one seems to care.

Deanna

Thanks, Deanna,

We've had this discussion on the list in the past.

It is OK to give a prompt pay discount - the argument being that you would give private insurances the same prompt pay discount if they paid at time of service.

The 2 concerns that were brought up in the past are...

1. If your prompt pay discount is less than what you give to insurances and/or the discount is less than Medicare and you have a significant amount of cash pay patients - insurance may argue that your usual and customary payment is actually the discount and not the higher amount you charge the insurance.

2. I was not arguing this Prompt Pay Discount point - I was arguing the issue that doing cash pay is fine, but contractually, you must submit the bill to the patient's insurance - unless it is something known to not be covered (ie acupuncture and Medicare). So if the patient has insurance, the flu shots are probably a covered benefit and so you need to submit the charge to that insurance. Also, even though you may be giving a discount - perhaps some insurances allow even less than the cash discount - and the patient would have been charged less than the amount of the discount if the charge had been submitted to insurance - that is where I think one could get into trouble with insurances.

That's the point I was trying (unsuccessfully) to make.

Thanks

Locke, MD

,

Having worked now in retail care for a couple of years (those clinics staffed by NPs inside stores), I think I know the answer to this question. These clinics offer a set of services for a cash-pay price -- for instance, $29 for a sports physical, $25 for a flu shot, etc. These are advertised on their web site, on a television at the front of the clinic, and are quoted to patients at the desk and over the phone.

The clinic also bills most commercial insurers, Medicare, and TriCare. Medicaid won't contract with some of these clinics because they don't meet all the Medicaid requirements. Medicare allows these cash-pay, on-the-same-day discounted fees to stand because the patient is paying at the time of service. It is called a "prompt-pay discount." It cannot be paid at a later date or billed in any way. Credit card, cash, or check must be collected at the time of the visit.

Medicare allows this because it assumes the provider does not have the cost of billing added to the fee -- and that includes all the costs of billing. The prompt-pay fees must be the same for everyone, so I can't charge one person $25 and another person $15 for a flu shot, unless I have changed the price for everyone.

I can't quote you the chapter and verse in the Medicare documentation, but I know it exists or all these retail clinics would be committing Medicare fraud -- and I'm sure their lawyers have already figured out where the chapter and verse are.

Hope that helps, and hope I'm right.

Deanna

Deanna,

I think many practices do what you mention below, but I've always wondered about the legality of it -- or at least the contractuality of it.

My understanding has always been - if a service is covered by insurance and we are contracted with that insurance - we can't just take cash and not bill the insurance.

One can probably get in trouble coming and going.

If I charge $100 for a CPT code to insurance, but insurance pays $80 and I allow the patient to have it for $50 -- the insurance is going to wonder why they don't get it for $50 - since it is below what they allow.

Converseley, if you charge $100 and the insurance pays $80, but you give a "discount" to the patient of 10%, so they only pay $90 -- the insurance (and probably the patient) is going to say that you can't do that because the allowed from the insurance would have been $80 - so you overcharged the patient.

Anyway, that has always been my take on it.

If the insurance pays for a CPT code - I can never just take cash - I have to submit the bill.

But I could be wrong.

Anyone have experience with this issue?

Locke, MD

I have about 70 doses left. Any idea about how to advertise this without spending much money? I've lowered my price to $15 (pay at the time of visit). Hate to see this go to waste -- and would like to cover my vaccine bill!

Deanna, FNP

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