# You can't treat patients differently



## rhedges (May 24, 2016)

Is there a written guideline that specifically states "you can't bill patients different amounts for services received based on insurance or financial ability to pay"?  This is repeated statement in the billing field.  I am seeking a statement in writing to support this issue.  My example is 2 different patients receive the same 2 exact services.  1 patient is covered under BCBS with a copay and 1 patient is a self pay patient.  The physician wants to only bill the self pay patient for 1 service due to financial constraints.  Is this legal?


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## mitchellde (May 25, 2016)

It is called the false claims act.  You cannot bill one entity different from a an other.  You have a stated fee schedule and this us what you are required to charge.  You must bill from the documentation.  There is also the most favored nations cause that states you cannot charge any one entity an amount that exceeds that which you charge your least charged for the exact same service.  It means the same thing as you charge everyone what you have stated on the fee schedule.


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## cgaston (May 25, 2016)

You need to bill the same amount for the same service. 

If your physician wants to give the self pay patient some kind of "special consideration" then he can apply that reduction towards the charge but the original fee for the procedure should be the same for everyone.


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## rhedges (May 25, 2016)

I think my question may have been to vague.  The physician is not wanting to change the price but rather not charge the self pay patient for the lesser of the 2 services.  If you can also direct me to the specific language within the False Claims Act, it would be greatly appreciated.  I just want to have my ducks in a row on this one.


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## JEYCPC (May 25, 2016)

http://www.falseclaimsact.com/common-types-of-fraud/health-care-fraud

and 

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.pdf


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## rhedges (May 25, 2016)

Thank you to everyone who weighed in on this issue.  Your assistance is greatly appreciated


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## rhedges (May 26, 2016)

I read all the articles referenced in this thread.  I was looking for the statement to "jump off of the page" about fairly billing all patients the same.  I don't know if I missed this statement or if a "False Claim" has alot inferred as to what can be considered fraud.  If anyone can point me to the specific page, paragraph, etc within all this legal jargon, my gratitude would be overwhelming.


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## mitchellde (May 26, 2016)

The language is fairly generic.  But look at it thus way.  You must code by the documentation.  To not code/bill for a procedure would be under coding/under billing. This is seen as equal to overcoding/over billing. now if a provider wants to provide a compassionate reduction due to financial issue or other extenuating circumstances, this is allowed, provided the financial is verified.  There should be a formula the state provides for reducing services based on financial need.  This tells the provider what proof needs to be provided to show the financial need and what percent can be taken off.  Usually the hospital social work department can help you with this.  If this is a different kind of compassionate care say a recent tragedy such as a house fire or sudden loss of loved one and the provider feels it is in the best interest of the patient to not charge, then this is permissible on a once in a lifetime type of basis per patient.    
You are never going to find the exact language in a piece of regulation that you are wanting.


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## avon4117 (May 26, 2016)

I thought you could have self pay rates?


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## thomas7331 (May 26, 2016)

The false claims act is more relevant to misrepresentation of information on a claim, and where you can run into trouble is if practice is actually willing to accept a lower amount as payment in full for services than what you are stating are your charges on the claim form.  It's questionable how that would apply to your particular situation since with a self-pay patient there is no claim involved.  What you're describing is a provider performing an instance of charity care for an uninsured patient which is a little different.  But you might want to take a look at this guidance from the OIG, there's a lot of good information here:

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

About half-way down, it says:  "When providers, practitioners or suppliers forgive financial obligations for reasons other than genuine financial hardship of the particular patient, they may be unlawfully inducing that patient to purchase items or services from them."

I think it's unlikely that you'd run into problems if these are isolated instances done with the intent of helping a patient who is in financial difficulty, especially if no government or commercial payer is involved, but to protect yourself the best approach is to have a written financial hardship policy and have some process in place to demonstrate that your practice is making an effort to collect payments and only forgiving charges in situations when there is a legitimate and verifiable hardship involved.  

Hope this helps some.


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## rhedges (May 26, 2016)

Our coders are awesome!!!!  For those who provided your insight, it sheds a lot of light on the subject and I am going to be able to present clear & concise info the the physician. I think it proves that so many physicians do have compassion for their patients in not wanting to gouge their checkbooks but rather truly care for them.

Thanks again to all


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## mitchellde (May 26, 2016)

avon4117 said:


> I thought you could have self pay rates?



you are not suppose to have a different fee schedule for self pay than that which you use to charge all other payers.  the same service cannot be different amounts based on whether you are insured or not.  with high deductibles , if you told me I could pay out of pocket a rate that would be lower than what I would have to pay with my insurance deductible, then why would I tell you I have insurance?  If Medicare discovered that you were charging a lower rate to some individual than what you represented to them as the charge for the same procedure , don't you think that would matter?  having a separate fee schedule for self pay is not a great idea and in some states there are state laws that do state this is not allowed.  
In addition consider the insured individual they not only pay premiums each month, they also must pay a copay or deductible, if you make it more attractive for self pay, you are providing an incentive to not be insured.


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## lexy1011@gmail.com (Aug 13, 2021)

Unfortunately I don't have a specific legal reference for this, but in terms of what makes sense to me:

The charge should be the same for everyone. Patients need to all be treated equally and be billed (or have their insurance billed) for all of the services they received, if documentation supports.

The key part involves what the provider chooses to write off for self pay patients. It would be considered charity/financial assistance and can be adjusted however they want.


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## kseebeck (Aug 16, 2021)

If your office is providing charity or financial assistance to patients, there should be a policy that clearly defines that process so it is applied equally to all patients.


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## Ecode405 (Jan 14, 2022)

I'm new to the office. There is a patient who is being seen for Depo injections. The patient's insurance does not cover the injections (the provider is in network with her plan). For the administration the patient has (for quite some time) been allowed to pay less than the provider's fee for the administration. I didn't think we could do this - I thought that the claim should be filed and a denial received indicating what was owed to the provider (in case of repricing on the part of the patient's plan).


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## thomas7331 (Jan 14, 2022)

Ecode405 said:


> I'm new to the office. There is a patient who is being seen for Depo injections. The patient's insurance does not cover the injections (the provider is in network with her plan). For the administration the patient has (for quite some time) been allowed to pay less than the provider's fee for the administration. I didn't think we could do this - I thought that the claim should be filed and a denial received indicating what was owed to the provider (in case of repricing on the part of the patient's plan).


If it's known that the service is not a covered benefit under the plan, or if the patient has requested that the claim not be filed to their plan, there is no obligation for the provider to file the claim.  

This is a different situation from a service that is covered but not paid because it is applied to a deductible or cost-share.  Payers should not be repricing services that are not benefits because those services are excluded from coverage and don't fall under the provider's contractual obligations.  If they are discounting services that aren't a benefit, this is likely a payer error.


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