Third party billing for non-physician surgical assistants - Issues and trends: Presentation at the 2014 NSAA Annual Conference in Washington, DC

1. Third Party Billing for
Non-physician Surgical Assistants
Issues and Trends
Luis F. Aragon, CSA,RSA, LSA
National Surgical Assistant Association
2014 Annual Conference
Washington, DC

2. Terms to know
• Out of Network: It refers
to a provider that does
not have a contract with
an insurance carrier.
• Out of network and in
network out of pocket
amounts are calculated
separately.
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3. Life Cycle of an Insurance Claim
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4. Clean claim
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5. Patients can be billed for non-covered procedures, but not
for unauthorized services.
Claims are adjudicated by line item (not for total charges),
which means that payers bundle and edit code numbers for
individual procedures and services (Unless referred to third
party companies for negotiation)
The patient is responsible for co-payments and deductibles,
but does not pay more than the allowed negotiated rate.
Facts to know
Luis F. Aragon, CSA, RSA, LSA

6. Out of Network Legislation examples
• COLORADO:
West's C.R.S.A. § 10-16-704, "Network adequacy," mandates a
certain payment level for claims filed by nonparticipating medical
providers under certain specified circumstances.
• ILLINOIS
1) covered services are not available from a contracted provider; and
2) the member has made a good faith effort to use the services of a
contracted provider but such services are unavailable. In these
instances, provider/payor agreements must contain a provision
whereby the covered member will be provided a covered service at
no greater cost than if such service had been provided by a
contracted provider (50 IAC 2051.55 (e)(10)(A)).
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7. No Out of Network benefits
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8. Co-insurance
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9. No balance billing allowed
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Surgbill

10. Deductible
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Surgbill

11. Co-insurance
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Surgbill

12. To bill or not to bill! (Patients)
This has been an issue of debate nationwide in
the Surgical Assistant industry for decades
now.
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 strongly recommend billing for deductibles
and co-payments, but strongly advise against
balance billing or when the plan does not have
out of network benefits. (State based)
Luis F. Aragon, CSA, RSA, LSA

13. AMA Council on Ethics and Judicial Affairs
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.html
Luis F. Aragon, CSA, RSA, LSA

14. 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, CSA, RSA, LSA

15. 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.
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16. 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, CSA, RSA, LSA

17. 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, CSA, RSA, LSA

18. 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.htm
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19. What Does OIG Say?
• Waivers of Cost-Sharing Amounts For
Financially needy Medicare & Medicaid Patients
Permitted:
1) Waiver must not be routine;
2) Waivers may not be offered through
advertisement or solicitation;
3) 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.pdf
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20. Best practice tip
Provide an Assignment of Benefits (AOB) to the patients to sign where
they are allowing you to submit the claim to their insurance company.
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21. A unique ten character alphanumeric
code that enables providers to identify
their specialty at the claim level.
Designed to categorize the type,
classification, and/or specialization of
health care providers.
Administered by the National Uniform
Claim Committee which is chaired by
the AMA with a critical partnership with
CMS.
Taxonomy code
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22. • No, the codes are self-selected by the provider
http://www.nucc.org/index.php?option=com_content&view=article&id=97&catid=
18&Itemid=128
Does choosing a taxonomy code mean I met the licensure /
certification requirements for that provider?
Luis F. Aragon, CSA, RSA, LSA

23. • You do not need to have that source’s certification
to choose the code. The sources for the definitions are
only to cite who authored the definition.
http://www.nucc.org/index.php?option=com_content&view=article&id=98&catid=18
&Itemid=128
Do I have to have the definition source’s
certification in order to choose the code?
Luis F. Aragon, CSA, RSA, LSA

24. The Health Care Provider Taxonomy code set is published
(released) twice a year in July and January.
The July publication is effective for use on October 1st
and the January publication is effective for use on
April 1st.
The time between the publication release and the
effective date is considered an implementation
period to allow providers, payers and vendors an
opportunity to incorporate any changes into their systems.
http://www.nucc.org/index.php?option=com_content&view=article&id=102&catid=18&It
emid=128
When is the code list published?
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25. Luis F. Aragon, CSA, RSA, LSA
WHAT IS AN NATIONAL PROVIDER IDENTIFIER
(NPI)?
• Is a healthcare provider’s
unique 10- digit number
used by insurance carriers to
identify providers.

26. Round Table Discussion
• Steven K. Young, CSA – Washington
• Michael Orstead, CSA - Virginia
• Debbie Ivory, CSA - Virginia
• Kathleen Duffy, CSA - Florida
• Luis F. Aragon, CSA - Illinois