Does anyone know if its illegal for a doctor to waive a copay???

My BIL is a podiatrist and I asked him to waive a copay for a quick visit and he said he cant because of insurance reasons. I just think he is being cheap because thats how he is in his daily life.

The ped waive a copay once so Im thinking its okay and my BIL is just being a d0uche.

Does anyone know?

Message edited 8/13/2011 8:30:50 AM.

Re: Does anyone know if its illegal for a doctor to waive a copay???

I don't know for sure it it's illegal, but I don't think it is. I am friends with some doctors and they have always waived their co-pays for me. I think it's also fairly common for doctors to waive their co-pays when treating other doctors and their families.

Re: Does anyone know if its illegal for a doctor to waive a copay???

Funny, I was just talking about this the other day.
My old Ped had a sign that says "If you ask us to waive your co-pay, you are committing insurance fraud"

Re: Does anyone know if its illegal for a doctor to waive a copay???

There has been times where they just forgot to ask me for it lol

Re: Does anyone know if its illegal for a doctor to waive a copay???

There is something true to that. I do not know specifics but if a Dr is going to bill an insurance company, it is required that a copay be collected. It has to do with certain insurances and if the Dr gets audited I believe that the insurance company can drop them if they have a habit of not collecting copays. Again this is what I have heard not saying it is 100% accurate.

Re: Does anyone know if its illegal for a doctor to waive a copay???

The routine waiver of co-payments and/or deductibles can constitute a violation of the federal anti-
kickback statute (42 U.S.C. Section 1320a-7b) as well as applicable state law.

The federal anti-kickback statute prohibits the payment of remuneration (which includes the transfer of anything of value) to
induce referrals of business for which payment may be made by the Medicare or Medicaid programs. In essence, by routinely waiving co-
pays or deductibles, you are encouraging – or inducing – patients to come to your practice rather than others – and expecting Medicare to
cover your generosity.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) further provides for civil monetary penalties for offering or
transferring remuneration to Medicare and Medicaid beneficiaries that the physician knows or should know is likely to influence the
individual to receive covered services from the physician.

The routine waiver of co-payments and deductibles can also constitute insurance fraud. (For example, if an insurance company agrees to pay a physician 80 percent of his or her usual and customary charges, and the physician submits a claim for $100 but routinely waives the $20
co-payment, the insurance company could argue that the physician's usual and customary charge is $80 rather than $100. In that event,
the insurance company might be responsible for only 80 percent of the $80 charge or $64).

In general, waivers of co-payments and deductibles are permitted only if they are not advertised, not routine, and are granted only to
financially needy patients or where a reasonable collection effort has been made. (See below for addt'l info. on this issue).
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2) Question: Is it legal to discount our fee schedule for Medicare patients who are broke? Can we waive copays for these people?

Answer: The Department of Health and Human Services issued a statement allowing discounts and copay waivers for indigent patients
visiting hospitals, but it does not specifically address physician practices.

The OIG does allow occasional copay waivers if physicians have tried to collect and patients are experiencing financial hardship. Here is
its statement: http://oig.hhs.gov/fraud/...andbulletins/121994.html

"One important exception to the prohibition against waiving copayments and deductibles is that providers, practitioners or
suppliers may forgive the copayment in consideration of a particular patient's financial hardship. This hardship exception, however, must
not be used routinely; it should be used occasionally to address the special financial needs of a particular patient. Except in such
special cases, a good faith effort to collect deductibles and copayments must be made. Otherwise, claims submitted to Medicare may
violate the statutes discussed above and other provisions of the law."

We never advise providers routiinely to bill "insurance only." Discounts and waivers should happen in limited circumstances and
should be applied consistently -- that is, you should treat all patients the same.

You may also be interested in the American Medical Asociation's position on copay waivers (this includes deductibles):

E-6.12 Forgiveness or Waiver of Insurance Co-payments.

Under the terms of many health insurance policies or programs, patients are made more conscious of the cost of their medical care
through co-payments. By imposing co-payments 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 co-
payment for the care. Physicians commonly forgive or waive co-payments to facilitate patient access to needed medical care. When a
co-payment is a barrier to needed care because of financial hardship, physicians should forgive or waive the co-payment.

A number of clinics have advertised their willingness to provide detailed medical evaluations and accept the insurer's payment but
waive the co-payment 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, violates Opinion 2.19, and is unethical.

Physicians should be aware that forgiveness or waiver of co-payments 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 co-payments may constitute fraud under state and federal law. Physicians should ensure that their policies on co-payments are
consistent with applicable law and with the requirements of their agreements with insurers. (II) Issued June 1993.
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3) Question: I routinely waive copays for patients who have waited a long time to see me or who are in financial distress. My
administrator tells me this is illegal. Is it?

Answer: Probably. In May 1991, the Office of the Inspector General (OIG) of the Department of Health and Human Services issued a "fraud
alert" concerning waiving co-pays for Medicare patients. Essentially, they said that routinely waiving copayments for Medicare
beneficiaries, if you are paid on the basis of charges, is considered fraud.

Here is their exact language:

"To help reduce fraud in the Medicare program, the Office of Inspector General is actively investigating health care providers,
practitioners and suppliers of health care items and services who (1) are paid on the basis of charges and (2) routinely waive (do not
bill) Medicare deductible and copayment charges to beneficiaries for items and services covered by the Medicare program.

This fraud alert is not intended to address the routine waiver of copayments and deductibles by providers, practitioners or suppliers
who are paid on the basis of costs or diagnostic related groups. The fact that these types of services are not discussed in this fraud
alert should not be interpreted to legitimize routine waiver of deductibles and copayments with respect to these payment methods.
Also, it does not apply to a waiver of any copayment by a Federally qualified health care center with respect to an individual who
qualifies for subsidized services under a provision of the Public Health Service Act."

The OIG considers it fraudulent to waive copays because:

· You end up "misstating" your actual charge — and forcing Medicare to pay out more than it should. Here's the OIG's
example: "For example, if a supplier claims that its charge for a piece of equipment is $100, but routinely waives the copayment, the
actual charge is $80. Medicare should be paying 80 percent of $80 (or $64), rather than 80 percent of $100 (or $80). As a result of the
supplier's misrepresentation, the Medicare program is paying $16 more than it should for this item;"

· Waiving copays may induce patients to see you rather than other providers. That violates anti-kickback rules; and

· HCFA wants Medicare beneficiaries to be good, thoughtful consumers of healthcare. Copays are designed to incentivize patients
to think twice about coming in for care that may be unnecessary. By waiving copays routinely, you ruin that incentive program — and cost
Medicare more.

Punishment for fraud in this area is serious. According to the Civil Monetary Penalties law, you could be liable for up to $10,000 for
each service fraudulently billed, $15,000 for each individual whose copay you waived, and $10,000 for each day your "coercive"
relationships with a patient continued. You can also be kicked out of the state healthcare program.

The OIG does understand that there need to be exceptions to the copay rules for truly needy people. However, these should be exceptions,
not the routine. You'll need to carefully assess each patient's financial hardship, not dismiss copays as a general rule for anyone who complains.

You can read the full OIG fraud alert on this subject at www.dhhs.gov/progorg/oig/frdalrt/121994.html.

Of course, all this applies only to Medicare. If you waive copays for patients in private plans, your legal obligations are spelled out in
your payer contract. If you have agreed to collect copays in a legally binding contract, you had better collect the copays. In
general, waivers are permitted only if they are not advertised, not routine and are granted only after a resonable effort to collect.
Check each of your contracts to understand your obligations.
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4) Question: Can we offer courtesy professional discounts to other physicians?

Answer: According to attorney Todd Rodriquez of Philadelphia-based Gosfield & Associates, professional courtesy discounts can raise
issues under the federal anti-kickback and false claims statutes, whether the discounts are given under Medicare or with commercial
insurances.

Certainly, don't give discounts and free services to physicians or others that make or influence referrals to the practice; that makes
the service or discount appear could be construed to be kickback. In other circumstances, if you do provide courtesy discounts, set a
policy to write off the entire charge and not just the copay. Medicare and commercial payers may view the routine waiver of copays
as a misstatement of the physician's actual charge, resulting in false claims liability.

In addition, case law supports commercial payers who may say that since the patient didn't incur any costs, it has no obligation to pay
for anything since insurance exists to pay for financial risk associated with services. If there is no charge, there is no
financial risk to insure.

Re: Does anyone know if its illegal for a doctor to waive a copay???

The contract that doctors and dentists sign to become credentialed with insurance companies states they are responsible for collecting all co-pays. It is absolutely a form of insurance fraud to not collect it.
The reason is-your insurance company paid 100% of their responsibility and you didn't pay yours.
However on select situations the doctor(provider) can state on the claim form "the patient is not participating in the cost of treatment" and the insurance company may elect to lower their portion of payment as well which means the doctor provider receives even less money toward treatment.

I am not saying that I have never seen doctors accept insurance only on family members, but techically it is illegal.

Re: Does anyone know if its illegal for a doctor to waive a copay???

never knew this..my dentist is a close family friend and i've never paid a penny for anything..if he gets insurance on me he uses it, but i have't even had insurance bc i don't feel the need to pay for it with him..

Re: Does anyone know if its illegal for a doctor to waive a copay???

There probably is some contractual agreement between him and the insurance company that he will charge co-pays as part of payment but there is no way the insurance company would ever find out if a patient did not pay a co-payment.

Message edited 8/13/2011 11:22:14 AM.

Re: Does anyone know if its illegal for a doctor to waive a copay???

It is insurance fraud to do this!!! You cannot waive a copay. He is telling the truth.

Re: Does anyone know if its illegal for a doctor to waive a copay???

It's true, he isn't lying. OIG considers it to be fraud. He has to attempt to bill you, even once, no matter how small the copay is (we used to have to bill .80 copays. It cost us more to mail them)

He doesn't have to enforce collecting it though. We had bills under $10 we would send once and write off in bulk. Perfectly fine since we could show a papertrail of attempting to collect.

Re: Does anyone know if its illegal for a doctor to waive a copay???

I work for North Shore/Lij hospital. I am a medical biller and we are told we must collect every single copay. None are to be waived this is including other drs, family members etc. I belive it is some kind of violation to do this.

Re: Does anyone know if its illegal for a doctor to waive a copay???

It's insurance fraud. And yes, the insurance companies can find out about it. All it takes is one ****** off patient or disgruntled employee to report you.

Re: Does anyone know if its illegal for a doctor to waive a copay???

Message edited 8/13/2011 5:35:44 PM.

Re: Does anyone know if its illegal for a doctor to waive a copay???

Re: Does anyone know if its illegal for a doctor to waive a copay???

Re: Does anyone know if its illegal for a doctor to waive a copay???

Re: Does anyone know if its illegal for a doctor to waive a copay???

Message edited 8/14/2011 5:58:32 AM.

Re: Does anyone know if its illegal for a doctor to waive a copay???

Posted by mzsocialworker1

Posted by missrock

Posted by mzsocialworker1

Posted by missrock

My BIL is a podiatrist and I asked him to waive a copay for a quick visit and he said he cant because of insurance reasons. I just think he is being cheap because thats how he is in his daily life.

The ped waive a copay once so Im thinking its okay and my BIL is just being a d0uche.

Does anyone know?

If I knew a family member I was doing a favor for spoke this way about me, I'd absolutely charge them a co-pay, and honestly, probably make them wait to see another podiatrist.

Being married to someone who is self-employed, I certainly know there are people out there who take advantage and have this kind of attitude.

He's also in business so why shouldn't he charge you?

Just because you are related to him doesn't give you a free pass IMHO.

This is one of the reasons why I have to pay out of my own pocket close to $400.00 a WEEK in health insurance. Just sayin' :D

Before you get all nasty about the way I am talking about a family member being cheap, you need to know both stories. My BIL is a the cheapest person I know and to be honest I 'd rather give another doctor my money before I ever give him a dime of mine for a service that I can get elsewhere. The only reason I wanted to go to him is the convenience of being able to go to his house anytime.

When you have experience the cr*p i have dealt with then you might think differently.

So please dont make me look like the bad person until you know the story.

Thanks

I'm sorry if you feel judged on LIF, but the way you continue to say this and how you use him "out of convenience" kinda still portrays YOU as the cheap, and no offense, but not in the nicest light.

I again am sorry that you are taking this as a personal attack, but that's the way it comes across, especially given my experience with my own DH. If you feel he treats you so bad to begin with, I just don't understand why you'd want to see him. Kinda leaves me .

Re: Does anyone know if its illegal for a doctor to waive a copay???

NM

Message edited 8/14/2011 7:40:05 AM.

Re: Does anyone know if its illegal for a doctor to waive a copay???

As far as I know it is insurance fraud if he doesnt collect a copayment.

DH keeps telling my mom this who thinks it is the best that her OBGYN waives her copay because she has been going to him for, forever.


Also, I thought it wasn't exactly ethical as a Dr. to treat your own family and friends. I could be totally off on this, DH is a psychologist so for his profession it is unethical. Not sure if this is true for all doctors

Re: Does anyone know if its illegal for a doctor to waive a copay???

I think it's pretty ballsy to even ask for a doctor to waive a copay. You're asking him to put his job at risk and then you get upset that he won't do it?

Re: Does anyone know if its illegal for a doctor to waive a copay???

geez, all this info is kinda worrying me. My chiropractor whom I love to pieces gives me a 'deal' for a year's worth unlimited and I just pay that up front, instead of paying co-pays for each visit. It is an unreal deal when I look at it and kinda worries me...can it come back to bite me in the butt?

Re: Does anyone know if its illegal for a doctor to waive a copay???

Re: Does anyone know if its illegal for a doctor to waive a copay???