Wiki Supercoder, CPC, CPC-D

[DONNA GRIMM]

Can anyone direct me to documentation on the guidelines of TWIP (take what insurance pays)? I know this has been a no no for many years but I am having a problem with my docs writing a discounted price for a procedure on an ABN because they expect the insurance to deny the claim as not medically necessary. Am I wrong that it is illegal to "write off" any balance that the insurance does not pay to insure that the patient pays only the "agreed upon discounted price" for the procedure. Example: billed insurance total amount of $500.00 but told patient that their responsibility would only be $200.00 if insurance didn't pay. My understanding was that you give the patient a choice of either submitting to insurance & they sign an ABN to pay what insurance does not pay OR you have them signa a "cosmetic waiver" & they pay the "agreed upon price" up front without billing to insurance at all. Please help!

 

[ajs]

Can anyone direct me to documentation on the guidelines of TWIP (take what insurance pays)? I know this has been a no no for many years but I am having a problem with my docs writing a discounted price for a procedure on an ABN because they expect the insurance to deny the claim as not medically necessary. Am I wrong that it is illegal to "write off" any balance that the insurance does not pay to insure that the patient pays only the "agreed upon discounted price" for the procedure. Example: billed insurance total amount of $500.00 but told patient that their responsibility would only be $200.00 if insurance didn't pay. My understanding was that you give the patient a choice of either submitting to insurance & they sign an ABN to pay what insurance does not pay OR you have them signa a "cosmetic waiver" & they pay the "agreed upon price" up front without billing to insurance at all. Please help!

Here is a recent guideline from the American Medical Association (AMA):

"Ethical Opinion 6.12 - Forgiveness or waiver of insurance copayments.
Under the terms of many health insurance policies or programs, patients are made more conscious of the cost of their medical care through copayments. By imposing copayments for office visits and other medical services, insurers hope to discourage unnecessary health care. In some cases, financial hardship may deter patients from seeking necessary care if they would be responsible for a copayment for the care. Physicians commonly forgive or waive copayments to facilitate patient access to needed medical care. When a copayment is a barrier to needed care because of financial hardship, physicians should forgive or waive the copayment.

A number of clinics have advertised their willingness to provide detailed medical evaluations and accept the insurer's payment but waive the copayment for all patients. Cases have been reported in which some of these clinics have conducted excessive and unnecessary medical testing while certifying to insurers that the testing is medically necessary. Such fraudulent activity exacerbates the high cost of health care, is unethical, and violates Current Opinion 2.19. (Physicians should not provide, prescribe, or seek compensation for services that they know are unnecessary.)

Physicians should be aware that forgiveness or waiver of copayments may violate the policies of some insurers, both public and private; other insurers may permit forgiveness or waiver if they are aware of the reasons for the forgiveness or waiver. Routine forgiveness or waiver of copayments may constitute fraud under state and federal law. Physicians should ensure that their policies on copayments are consistent with applicable law and with the requirements of their agreements with insurers."