THE EFFICIENT OPHTHALMOLOGIST

Doc, can you cut me some slack?

When patients don’t pay their bills.

By Steven M. Silverstein, MD, FACS

Steven M. Silverstein, MD, FACS, is a corneatrained comprehensive ophthalmologist in practice at Silverstein Eye Centers in Kansas City, Mo. He invites comments. His e-mail is ssilverstein@silversteineyecenters.com.

How often are you asked by a patient to waive a co-pay, deductible or refraction fee? You may be faced with this in the exam lane, but more often, this question is posed to your billing department after the patient receives the statement outlining the portion of the charges for which he or she is responsible, or at the front desk when asked for the appropriate payment.

TIMES ARE TOUGH

Times have always been tough-in any economy — especially when it comes to patients taking ownership of the uncovered charges associated with medical services. It’s funny how quickly some patients forget how miserable they were because of symptoms that precipitated their office visit, when weeks later, long after the resolution of their symptoms, they receive their portion of the bill from the insurance company for the uncovered charges associated with medical services. After multiple phone calls and certified letters, the frustrated staff in the billing and collections department places a stack of charts on the doctor’s desk to determine a final disposition: write off, collect at the time of the patient’s next appointment or send the patient to collections.

This is a painful part of running your own business. On the one hand, it is frustrating when patients simply refuse to pay for your best efforts to help them feel better. After all, they made the appointment to see us. Why would they be so disrespectful?

Looking back at the chart, their chief complaint was successfully managed, or your clinical judgment uncovered issues of which they were never aware (glaucoma or macular degeneration, for example). On the other hand, it is also painful to jeopardize a patient’s credit by sending them to collections for a $50 bill.

Further, if the patient ignoring his responsibility is referred by another physician and that patient is dunned or “harassed” by your billing department or sent to a collection agency, the genuine fear exists the negativity that ensues will be reported to the referring doctor, which threatens the likelihood of future referrals regardless of the quality of your care.

What really burns you up is being called into the emergency room or an inpatient consult to see the patient of a competing practice because the patient’s regular doctor does not take calls at the hospital, or because the patient has no regular eye doctor, and then you do not get paid for the consultation because the patient is uninsured, or simply ignores your office’s requests for payment.

WHY WRITE-OFFS OCCUR

Several reasons can be given as to why physicians may elect to write off charges. By far the vast majority of charges are excused due to reported patient financial hardship. We hear it every day: patients who are disabled, lost their jobs, widowed without their spouse’s benefits, living solely on Social Security, cannot afford the co-pays and the medicines each of their doctors insist they need.

Less frequently, doctors may waive a patient’s co-pay and other charges due to professional courtesy or because of a close relationship with the patient or the patient’s family. Lastly, and most egregious, some doctors will discount or write off appropriate charges as a subtle form of marketing or inducement by letting it be known that they collect insurance only or do not collect copays or deductibles.

THE LAW IS CLEAR

What specifically, does the law demand of us, and why?

The following is directly from the Office of the Inspector General (OIG):

“Routine waiver of deductibles and copayments by charge-based providers, practitioners or suppliers is unlawful because it results in (1) false claims, (2) violations of the anti-kickback statute, and (3) excessive utilization of items and services paid for by Medicare.” Further, “A provider, practitioner or supplier who routinely waives Medicare co-payments or deductibles is misstating its actual charge. In certain cases, a provider, practitioner or supplier…also could be held liable under the Medicare and Medicaid anti-kickback statute.

“When providers, practitioners or suppliers forgive financial obligations…they may be unlawfully inducing that patient to purchase items or services from them. Whoever submits a false claim to the Medicare program (for example, a claim misrepresents an actual charge) may be subject to criminal, civil or administrative liability for making false statements and/or submitting false claims to the Government.”

FORGIVING PAYMENTS

Circumstances do exist in which forgiving a co-payment or deductible is permitted, such as in cases of documented significant financial hardship. In this situation, the physician or his/her representative may submit specific financial information along with the claim that documents the details of the financial hardship. Physicians are then instructed to make a good faith effort to collect the waived deductibles or co-payments over time. Good luck with that.

These regulations, mandated by the government, are to be followed in cases of non-Medicare/Medicaid commercially covered services as well, punishable by the same penalties. The companies wholeheartedly agree, stating that if a doctor is willing to accept a discounted fee for services by waiving the co-pay or deductible, then perhaps the services are overvalued by the third-party carriers, and if such a waiver is granted, then the insurance company should be notified.

Of course, I strongly advise that you file waiver exemptions and write–offs, even for financial hardships, infrequently lest a red flag be thrown on the field of medical jurisprudence.

Ahhhhh. I don’t know what to tell you. I share the same frustration and motivation that all ethical ophthalmologists share. In this environment of medical scrutiny and oversight, we would at least like to feel as though we have the privilege of deciding what is best for our patients, both medically and economically, without being taken advantage of, or threatened with imprisonment. Literally. OM