Understanding health insurance reimbursement for Surgical Assistants


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This brief presentation describes the basics of third party billing for Surgical Assistants.

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  • Let me tell you what specifically I am going to talk about, I am going to talk about reimbursement but not about billing.
  • Understanding health insurance reimbursement for Surgical Assistants

    2. 2. Managed Care Models Exclusive provider organizations (EPO) Integrated Delivery System (IDS) Health maintenance organizations (HMO)  Direct Contract model  Group Model  Individual Practice Association  Network model  Staff model Point of service plan (POS) Preferred Provider organization (PPO) Triple option planLuis F. Aragon, RSASurgbill Inc.
    3. 3. CONSUMER DIRECTED HEALTH PLANS (CDHP) They are becoming a popular alternative to the increased costs of traditional health insurance premiums and the limitations associated with managed care plans.  Tax exempt accounts  High deductible insurance policy  Disadvantage is the gap between the expenditure of the account and the deductible.  We as SAs need to monitor this one closely as we do not know how is it going to play out in the future.Luis F. Aragon, RSASurgbill Inc.
    4. 4. Clean claimLuis F. Aragon, RSASurgbill Inc.
    5. 5. Life Cycle of an Insurance ClaimLuis F. Aragon, RSASurgbill Inc.
    6. 6. Terms to know Coordination of Benefits (COB) Non-covered benefits vs unauthorized services Allowed charges for the CPT in question Deductible Co-insurance Co-payment ERA vs EOBLuis F. Aragon, RSASurgbill Inc.
    7. 7. Facts to know Patients can be billed for non-covered procedures, but not for unauthorized services. Providers process denials of unauthorized services as a business loss. Claims are adjudicated by line item (not for total charges), which means that payers bundle and edit code numbers for individual procedures and services. Each payor may be different in their code edits. Payors are known for not applying official coding guidelines for ICD-9 and CPT codes. The patient is responsible for co-payments and deductibles, but does not pay more than the allowed negotiated rate. Luis F. Aragon, RSA Surgbill Inc.
    8. 8. No Out of Network benefitsLuis F. Aragon, RSASurgbill Inc.
    9. 9. Co-insuranceLuis F. Aragon, RSASurgbill Inc.
    10. 10. No balance billing allowedLuis F. Aragon, RSASurgbill Inc.
    11. 11. DeductibleLuis F. Aragon, RSASurgbill Inc.
    12. 12. Co-insuranceLuis F. Aragon, RSASurgbill Inc.
    13. 13. To bill or not to bill! (Patients) This is an issue of debate nationwide in the Surgical Assistant industry. Facilities and surgeons want the advantage of our services for free or for a minimal fee but do not want their patients to be bothered with an additional bill. We recommend billing for deductibles and co-payments, but strongly advise against balance billing or when the plan does not have out of network benefits. And even deductibles and co-payments fall in the out of network category, you have to make sure that your surgeons and facilities know that you are engaging in this practice. Facilities and surgeons prefer for us to be on the background much like the CRNAs, and this has worked as a win-win situation for both parties, but what is going to happen when CDHP plans start to take off?Luis F. Aragon, RSASurgbill Inc.
    14. 14. Bottom Line Your practice has to be prepared for the following issues: √ Billing patients and for what portions are you going to be billing √ Employer sponsored plans (e.gr., labor unions administered by BC/BS) make the determination to reimburse or not to reimburse from within and are regulated federally (ERISA) not by the State. √ All HMOs are federally regulated, therefore if they decide they do not want to reimburse, they don’t have to. √ Most commercial, PPOs, EPOs, BC/BS will reimburse for your services. √ Please be vigilent on some entities called ACOs, this is a direct result of Obamacare and it will start rolling out in January 2012.Luis F. Aragon, RSASurgbill Inc.
    15. 15. AMA Council on Ethics and Judicial Affairs Opinion Issued: The AMA has acknowledged that routine waivers of coinsurance/deductibles constitutes fraud, and proclaims the practice to be unethical. •http://www.ama-assn.org/ama/pub/category/4615.htmlLuis F. Aragon, RSASurgbill Inc.
    16. 16. AMA Council on Ethics and Judicial Affairs • Opinion 6.12 - Forgiveness or Waiver of Insurance Copayments: Physicians should be aware that forgiveness or waiver of co-payments may violate the policies of some insurers, both public and private….. Routine forgiveness or waiver of co- payments may constitute fraud under state and federal law.Luis F. Aragon, RSASurgbill Inc.
    17. 17. HIPAA Section 242 (Public Law 104-191 104th Congress) Title II, Subtitle E Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice-- (1) to defraud any health care benefit program; or (2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 10 years, or both.Luis F. Aragon, RSASurgbill Inc.
    18. 18. Fraudulent & False Statements  Professional courtesy discounts in the form of a waiver of a co-payment or deductible constitutes both health care fraud and false statements.  Knowing you are required to collect a co- pay or deductible but billing insurance only is committing health care fraud;  By billing an insurance company one charge but failing to collect the patient co- pay or deductible, the provider is making a false statement regarding the charge.Luis F. Aragon, RSASurgbill Inc.
    19. 19. What Does OIG Say? In 1991 the Office of Inspector General (OIG) issued a fraud alert concerning the wavier of co-pays and deductibles. The OIG stated that billing “insurance only” may violate the False Claims Act, the Anti- Kickback Statute, the Civil Monetary Penalties Law, 42 U.S.C sec 1320a-7a(a) (5), as amended by Pub.L.No 104-91 sec 231 (h), and State laws.Luis F. Aragon, RSASurgbill Inc.
    20. 20. What Does OIG Say? • Routine Waiver of Deductibles & Coinsurance Prohibited • 1994 Special Fraud Alert - http://oig.hhs.gov/fraud/docs/alertsandbulletins/121994.html • 1991 Safe Harbor Regulations Alert – • http://oig.hhs.gov/fraud/docs/safeharborregulations/072991.htmLuis F. Aragon, RSASurgbill Inc.
    21. 21. What Does OIG Say? • Waivers of Cost-Sharing Amounts For Financially needy Medicare & Medicaid Patients Permitted: 3) Waiver must not be routine; 4) Waivers may not be offered through advertisement or solicitation; 5) Waivers may only be offered after determining in good faith that there is a financial need or when reasonable collection efforts have failed •See testimony, Lewis Morris, Chief Counsel to OIG, 2004 http://oig.hhs.gov/testimony/docs/2004/40624oig.pdfLuis F. Aragon, RSASurgbill Inc.
    22. 22. What do I do then? PROVIDE AN ABN (Advanced Beneficiary Notice) during the first visit to your surgeon’s office: Your doctors utilize a Surgical Assistant during some surgeries that the hospital or your surgeon deem necessary, this assistant is not provided by the hospital. The fee for the assistant is 20% of the surgical charge, he/she will bill your insurance carrier, however if your insurance does not cover this service it will be your responsibility. In addition most insurance plans do not contract with Surgical Assistants and therefore this charge might be an out of network expense, please confirm with your insurance carrier for verification. CYALuis F. Aragon, RSASurgbill Inc.
    23. 23. Questions?Luis F. Aragon, RSASurgbill Inc.