Ophthalmology and Optometry Coding Alert

Question: We have a few patients at our practice who aren’t charged anything when they visit because they are friends of the doctor. There’s a note in their records saying, “Do not charge Blue Cross — all services gratis.” At my last practice, we weren’t able to do this because it was against insurer policy. Can we do this here?

Codify Subscriber

Answer: The ironclad answer will depend on your contracts with payers, but in many cases, insurers will require you to collect all copays, even for the doctor’s friends.

Although you may feel like you’re helping patients out by waiving their out-of-pocket expenses, either through routinely waiving copays or coinsurance payments or deductibles, it could land your office in hot water. The U.S. Department of Health and Human Services Office of the Inspector General (OIG) is pursuing some providers who engage in this practice and charging them with filing false claims and other fraudulent practices. Commercial service providers are bringing lawsuits against providers as well.

Insurance contracts often feature a financial incentive to use the in-network providers, with the use of out-of-network providers incurring higher rates. But because there’s a legally binding agreement, if a provider decides to unilaterally waive a patient’s deductible or copay, then the provider is reducing the covered person’s contractual obligation. So if you waive deductibles and co-pays, the provider is interfering with the contract with the insurance carrier, and that’s what puts you at risk.

Help patients uphold their (and your) contractual obligations for the provision of health insurance by always accepting copays, deductibles, and coinsurance. Don’t risk noncompliance or scrutiny from the OIG or litigation initiated by payers, even if you feel like you’d be helping a patient.