Waiving Deductibles & Copays – Is it legal?

Waiving deductibles and copays has always been a hot-button issue in the medical community. It can be difficult as a provider to charge a patient a copay if you feel they’ve been down on their luck and hurting financially. After all – especially therapy providers – seeing them week to week you can become close to them and sometimes providers just “feel bad” charging a copay.

But choosing whether or not to charge a copay is more than a personal decision – it’s a legal one. Especially for Medicare or Medicaid patients, refusing to charge a copay can get you in hot water. The Office of Inspector General has come down hard and very clearly on the routine waiving of copays. The OIG has stated, in a special fraud alert, that a “practitioner or supplier who routinely waives Medicare copayments or deductibles is misstating its actual charge” and has also insisted that waiving copays violates the anti-kickback statute. Even if you are not physically handing a patient cash for walking into your door – waiving their copay is very similar. By waiving their copay, you’re giving them an incentive to come to your practice instead of going elsewhere. That’s providing a kickback for them to come to you.

Aside from Medicare and Medicaid patients, it’s also important for you to charge commercial patients their due patient responsibility for the insurers you’re in network with. You have legally binding contracts with these carriers that require that you bill the patient exactly what is stated on the EOB – no more or no less. Charging less – and the insurance company becoming aware of it – could easily lead to contract termination. Some states also have laws on the books that extend the anti-kickback statutes to all patients, regardless if they are Medicare or Medicaid, so you could be violating Federal law as well.

So when is it okay to waive a copay? Depending on your contract with commercial insurance carriers, it may never be okay. Please be sure you reference it before coming to any agreement with any commercially insured patient. But for Medicare or Medicaid patients there is a way to do it on a patient by patient basis when appropriate. First you need to make sure you are not doing it across the board – you need to have stated, specific and consistent circumstances by which you will waive copays and they must be based on a patient’s individual financial need. Make sure you have a waiver on file that documents the patient’s financial needs, accompanied by your office’s policy – ideally with income requirements.

It’s so important to file federal and state guidance when it comes to running your practice. Minor issues like patient copays can get a practice into serious hot water and copays are not worth losing your practice over.

Billing for Pediatric Therapy and ADOS Testing

Pediatric Therapy and ADOS Testing

Billing for Pediatric Therapy and ADOS Testing – There is so much diagnostic and standardized testing that goes into pediatric therapy. It requires a lot of documentation and time that is integral to creating a successful care plan for a patient. A common question that arises from clinic owners and providers of pediatric therapy is about ADOS (Autism Diagnostic Observation Schedule) testing and whether speech therapists can be paid for the screening and documentation around it.

Please note that this article is focusing on ADOS testing if you feel you or a speech therapist employed by you is capable of doing the test and making that diagnosis. This article is not insisting that ADOS testing is appropriate to be done by every office or every situation. ASHA’s official stance is below.

Speech-language pathologists who acquire and maintain the necessary knowledge and skills can diagnose ASD, typically as part of a diagnostic team or in other multidisciplinary collaborations, and the process of diagnosis should include appropriate referrals to rule out other conditions and facilitate access to comprehensive services.

There is no specific procedure code for ADOS testing. Instead, ADOS testing falls under two developmental testing codes.

96112: Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour

96113: Each additional 30 minutes, should your testing exceed 1 hour

These codes cover both the actual test administration andthe reporting and interpretation that follows the test. You’ll want to be sure that you track your time spent both with the patient and working on the report afterward as they are both reimbursable.

Before billing these services you’ll want to ensure they are included in your fee schedule with any insurances you are in network with. Please note that these codes are not covered under the pediatric therapy fee schedule for Florida Medicaid and Florida Medicaid may require any diagnosis to be PCP-driven.