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This policy provides guidance to healthcare providers, employees and independent contractors of the school, departments and units that are a part of Rowan University School of Osteopathic Medicine, the RowanSOM Faculty Practice Plan and departments that bill federal or state programs for healthcare-related goods or services (“Related Healthcare Entity” or “Related Healthcare Entities) as to the appropriateness of Professional Courtesies for Healthcare Services.
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DEFINITIONS
Regulatory Guidelines
- Under Medicare and other federal and state programs, and based on the Health Portability and Accountability Act ("HIPAA"), effective January 1, 1997, the act of discounting services constitutes a violation of federal law and may subject the physician to civil penalties.
- Specifically, Section 231(h) of HIPAA provides for the imposition of civil monetary penalties against any person who offers or transfers remuneration to any individual eligible for benefits under Federal health care programs (including Medicare or Medicaid) that such person knows or should know is likely to influence such individual to order or receive from a particular provider, practitioner, or supplier any item or service for which payment may be made, in whole or in part, [by a Federal health care program].
- Section 231(h) defines "remuneration" as including the waiver or coinsurance and deductible amounts or any part thereof. The exceptions for waiving co-insurance or deductibles are: if it has been determined that the patient is in financial need or if the co-insurance or deductibles cannot be collected after making reasonable collection efforts.
- Other payers view the practice of submitting insurance claims based on a physician's or healthcare provider's actual charges and then failing to seek payment from the patient for the co-pay, deductible and/or remaining balance, as a fraudulent misrepresentation of charges. The practice of waiving co-insurance or deductibles results in an "overstatement" of the physician's charges, since the charge includes an amount that the patient is not being asked to pay. If the payer considers this a misrepresentation of the Related Healthcare Entity's charges they could legally reduce reimbursement by the discounted amount. Additionally, there are issues relative to discrimination and violation of contracts.
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By Direction of the President:
Signature on file
Chief Audit, Compliance and Privacy Officer
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