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Q I believe chiropractic services should be available to everyone. I have therefore retained the services of a transportation company that goes into an indigent area, picks up people at a community center and brings them to my office where they receive treatment. They receive whatever services are necessary and I get paid from Medicaid. Is there a problem with this practice from a legal standpoint?
A Health-care providers who offer free goods or services, such as transportation services, to federal health-care beneficiaries may be subject to civil monetary penalties. Furthermore, free transportation services may implicate the criminal anti-kickback statute that prohibits offering anything of value to any “person” (including a federal health-care beneficiary) to reward or induce referrals (including self-referrals) for items or services reimbursable under any federal health-care program.
The government has recognized that although many arrangements involving free transportation have important and beneficial effects on patient care, such services are sometimes an integral part of fraudulent or abusive schemes that may lead to inappropriate steering of patients, overutilization, and the provision of medically unnecessary services.
The government has identified several risk factors including, but not limited to, the following:
- The nature or type of free transportation services offered. Expensive transportation services such as limousines, airline tickets, or ambulance transports raise greater concerns.
- The geographic area in which free transportation services are offered. Services offered within a provider’s historic service area are less suspect than services offered outside its historic service area.
- The availability and affordability of alternate means of transportation.
- Whether free transportation services are marketed or advertised and, if so, how.
- The type of provider offering the free transportation services. Free transportation services offered by individual providers or small groups of providers, or by freestanding clinics are subject to greater scrutiny.
- Whether the costs of the free transportation services will be claimed directly or indirectly on any federal health-care program cost report or claim or otherwise shifted to any federal health-care program.
These factors are not exclusive, and the presence or absence of any one factor will not determine whether the government will subject parties to sanctions for providing free transportation services to patients.
Q Many of my patients are having serious financial problems as a result of the closing of three major plants in our community. I know that I may not arbitrarily waive co-pays or deductibles, but are there some hard rules I can follow so I can help these people out?
A Abiding by the following guidelines may prevent you from having a problem with respect to waiving co-pays and deductible:
- Prepare a written financial hardship policy for your practice mandating that only a supervisor may waive payment and that under no circumstances may an employee disclose the practice’s hardship criteria to the patient.
- Check all sources of income such as salary, social security benefits, pension payments, interest income, annuities, dividends.
- Get a copy of your local hospital’s policies and forms to prove you are abiding by community standards.
- Check published poverty guidelines such asaspe.hhs.gov/poverty/00poverty.htm regularly and update the information your offices uses. Charge a sliding scale based on these guidelines. For example, if the patient falls at 200%-300% below the poverty line, charge a 50% discount; if the patient falls more than 300% lower than the poverty line, charge nothing.
- Make sure you update the patient’s financial status regularly and document the patient’s file each time you discount care as a result of financial hardship.
Q Doctors in my town sometimes send me patients. I am not sure whether to bill these patients as a “consult” or as a “referral.” What’s the difference?
A In a consultation (also known as “second opinions”), you will be requested to check the patient, provide your assessment of the patient’s condition and send the patient back to the doctor who sent you the patient initially. In such a case, you bill for a “consult.” In a referral situation, you are sent the patient with the expectation that you will keep the patient. You would then bill for a “visit.”
In a case in which you expect to return the patient to the first doctor but you wind up keeping the patient, you may still bill for a consult initially because that was the intent of both you and the doctor who sent you the patient.
In a case in which you are being sent a patient to provide chiropractic care only and the referring doctor is still providing care to the patient, you must bill for a “visit.” s
Ms. Green has been a practicing attorney since 1977. She is admitted to the practice of law in New York and Florida. She has formed numerous integrated practices throughout the country and acts as counsel to a number of multi-discipline practice consulting firms.
Because this column is being presented to you by an attorney, it would not be complete without a legal disclaimer. This column is provided subject to and governed expressly by the terms of this disclaimer. This column is provided for educational purposes only. The accuracy or timeliness of the information presented herein is not warranted. The information presented herein is not intended to be advice as to a specific fact pattern with which you may be presented. Accordingly, please note that the information contained herein is not being presented as legal advice with respect to any matter and that no attorney-client relationship is hereby established.