Wiki Modifier -52 Use

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kljr1983

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Hi there,
I work for a Pediatrics company and our Dr.'s use modifier -52 on the Warts procedure 17110 to reduce the patient balance even though the procedure was completed and documentation does not warrant the appropriate use of mod -52 (i.e. procedure was started & not finished). I do not agree with the way we are using this modifier and also not all payers recognize the -52 as reducing the balance. We can't take an adjustment after insurance processes because that would be a violation of our payer contracts. Thoughts? Suggestions?
 
kblodgettCPC said:
Hi there,
I work for a Pediatrics company and our Dr.'s use modifier -52 on the Warts procedure 17110 to reduce the patient balance even though the procedure was completed and documentation does not warrant the appropriate use of mod -52 (i.e. procedure was started & not finished). I do not agree with the way we are using this modifier and also not all payers recognize the -52 as reducing the balance. We can't take an adjustment after insurance processes because that would be a violation of our payer contracts. Thoughts? Suggestions?
Click to expand...

My only suggestion would be to bill as normal, not using 52 - because you are now misrepresenting the services rendered. Unless, of course, it is true that "less than normal" services were rendered. In which case, you should educate your provider about making note of such in his documentation.

I am uncertain as to why you are not able to make an adjustment on the other end, after the insurance process. Do your contracts specifically prevent you from issuing a Courtesy/Charity Adjustment on the back end to cover the amount of co-insurance? I have never heard of an insurance company that cares whether or not the provider ever collects any amount of the co-insurance.
 
ABridgman said:
My only suggestion would be to bill as normal, not using 52 - because you are now misrepresenting the services rendered. Unless, of course, it is true that "less than normal" services were rendered. In which case, you should educate your provider about making note of such in his documentation.

I am uncertain as to why you are not able to make an adjustment on the other end, after the insurance process. Do your contracts specifically prevent you from issuing a Courtesy/Charity Adjustment on the back end to cover the amount of co-insurance? I have never heard of an insurance company that cares whether or not the provider ever collects any amount of the co-insurance.
Click to expand...

Of course the payers care if you collect the co-pay. This is a contractual agreement the patient made when they signed up and accepted the terms of the policy. Also the providers contract agreement with the payer states that the co-pay will be collected. You cannot adjust it off or reduce it. Some states have specific state laws that prohibit the writing off of co.pays and HIPAA has a provision in it that forbids this activity as well. Also as you stated you cannot use the modifier to try to lessen the patient amount. The patient will owe and must pay what they owe.
 
I said nothing about the co-pay.

I said the co-insurance.

I cannot tell you the number of times we have collected a co-pay or co-ins from a patient, only to have the doctor himself give it right back to the patient.

What do I do about such a situation? Do I go tell that patient, once again, that they have to pay that money? After the doctor himself already gave it back?

The fact is, the money WAS collected. I guess the doctor has a right to do whatever he will with the collected money.

Or do I have to sit down with my doctor and inform him that he can't do this?

EDIT: I know that the co-pay and co-insurance are amounts that the insurance contract says the insurance company won't pay...but is there actually any sort of regulation which requires the doctor to actually collect those fees? If so, what is done about people who simply do not pay? Or is just an attempt required? And what do you do about bad debt write-offs in such a case?

This doctor is located in Pennsylvania.

Can anyone cite me any regulations in state law (or in HIPAA) concerning this?
 
Last edited:
Thank you for the information.

Now...applying it to the condition I described...


Elements of the Prohibition
Remuneration.

Section 1128A(a)(5) of the Act prohibits the offering or transfer of “remuneration”.

The term “remuneration” has a well-established meaning in the context
of various health care fraud and abuse statutes. Generally, it has been interpreted broadly
to include “anything of value.”

The definition of “remuneration” for purposes of section 1128A(a)(5) – which includes waivers of coinsurance and deductible amounts, and transfers of items
or services for free or for other than fair market value – affirms this broad reading.

(See Section 1128A(i)(6).)

The use of the term “remuneration” implicitly recognizes that virtually any good or service has a monetary value.

3 The definition of “remuneration” in section 1128A(i)(6) contains five specific exceptions:

1. Nonroutine, unadvertised waivers of copayments or deductible amounts based on individualized determinations of financial need or exhaustion of reasonable collection efforts.

Paying the premiums for a beneficiary's Medicare Part B or supplemental insurance is
not protected by this exception.

THIS appears to allow what my doctor is doing - waivers of copayments or deductible amounts based on individualized determinations of financial need.

Am I interpreting this wrong, or is it okay for my doctor to do this - on financial need basis?

If so, then that is what should also happen with the original question about using the 52 Modifier...just waive/reduce the copayment/deductible amounts based on financial need. (I assume that is what was trying to be accomplished by use of the 52 Modifier??)

Similarly, would this apply to co-insurance amounts being waived - based on financial need?

This also answers the other questions about "reasonable collection efforts."

So how about it? Is my doctor okay with doing this?
 
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