Waiving Patient Balances: Co-insurance, Deductibles and CC Payment

Course Description

Waiving patient cost share responsibilities, including deductibles, coinsurance, and cc payments, carries significant legal risks for healthcare professionals. Both Federal and commercial healthcare programs and plans impose civil and criminal liability in case of non compliance. It is essential for healthcare professionals to grasp the intricate legal framework, rules and potential penalties associated with the waiver of patient cost share responsibilities today's healthcare landscape, understanding these complex regulations is imperative to protect both patients and medical practices. Failure to comply can lead to severe consequences, including legal actions, fines, and damage to professional reputation. Healthcare professionals must navigate the fine line between providing financial assistance to patients in need and adhering to strict legal requirements.

This session by federal licensed attorney, Thomas J. Force, ESQ. aims to shed light on these critical aspects. Thomas will delve into the nuances of the Federal False Claims Act and Anti Kickback statutes, exploring their defined penalties and implications for healthcare providers. Additionally, he will discuss practical strategies for drafting policies that align with financial hardship, professional courtesy and prompt payment, while staying within the bounds of the law.

Learning Outcomes

• Gain a comprehensive understanding of the hazards associated with waiving patient cost share responsibilities
• Learn why is waiving patient cost show responsibility so important
• Understand the Federal False Claims Act liability & penalties
• Know the Anti kick back liabilities and associated penalties
• Know the Impact of Federal health programs versus commercial health plans
• Health Plan sample language
• Learn how to analyze health plan documents relative to the prohibits of waiving patient cost share basis
• Know about professional courtesy, financial hardships, and prompt payment discounts and how to draft these documents compliantly
• The reasons why the routine waiving patient cost share is dangerous
• Key considerations in waiving patient cost share responsibility
• Impact of Medicare & federal healthcare programs versus commercial health plans
• Analysis of legal cases shaping the industry
• Exceptions - Where OMS can Waive or Discount Patient Balances

Areas Covered in the Session:

• Financial Hardship
• Whose money is it, anyway?
• Why is all of this so important?
• Medicare and Other Federal Plans
  • False Claims Act
  • Anti-Kickback Statute
  • State Laws
    • NY - Penal Law Section - 177
    • NJ - N.J. Stat. 2A:32C
• Commercial Plans 
  • Common law fraud
  • Violation of In-Network Participating Provider Agreements - Civil Liability
  • Intentional interference with contract rights
  • State Fraud Statutes - Civil and Criminal Liability
  • Beware of Financial Hardship Programs that are not commercially reasonable or vague
  • Courts concerned with discounts of patient cost share establishes a fee for some patients but not others
  • Claims of fraud and misrepresentation
  • Routine waiver of patient cost share
• Health Plan Language
• Relevant Cases
  • Horizon Blue Cross Blue Shield of New Jersey v. East Brunswick Surgery Center
• Does it matter if the Provider is out-of-network and has no contract?
• The View of the Feds - Waiving Patient Cost Share Responsibility
• View of Office of Inspector General
• Exceptions - Where OMS can Waive or Discount Patient Balances
  • Financial Hardship
    • What constitutes a Good Faith Determination of “Financial Need”?
  • OIG Safe Harbor
  • Professional Courtesy Discounts
  • Prompt Payment Discounts
    • Cannot be offered to induce patient to receive other services
    • Cannot be offered to induce patient referrals
    • State Laws may prohibit discounting patient cost share responsibility
    • Offering Cost Share Discounts may violate in-network participation agreements
• Noteworthy cases
  • Physicians Surgery Ctr. of Chandler v. Cigna Healthcare Inc., 609 F. Supp. 3d 930 (USDC of AZ. 2022)
  • North Cypress Med. Ctr. Operating Co., Ltd. v. Aetna Life Ins. Co., 898 F.3d 461 (5th Cir. 2018)
  • Conn. Gen. Life Ins. Co. v. Southwest Surgery Ctr., 349 F. Supp. 3d 718 (ND Ill. 2018)
  • Almont Ambulatory Surgery Ctr., LLC v. UnitedHealth Grp., Inc., 2015 U.S. Dist. LEXIS 183365 (CD Cal.)
  • Conn. Gen. Life Ins. Co. v. Elite Ctr. for Minimally Invasive Surgery LLC, 2017 U.S. Dist. LEXIS 21026 (SD Tx)
  • United States ex rel. Goodman v. Arriva Med., LLC, 2020 U.S. Dist. LEXIS 50783 (MD Tenn.)
• Live Q&A Sessions

Suggested Attendees:

• Healthcare CEOs
• Healthcare CFOs
• Healthcare COOs
• Healthcare Provider Revenue Cycle Staff
• Healthcare provider Office Managers and Billing Staff and Companies
• Healthcare Compliance Personnel
• Healthcare Attorneys
• Physicians
• Physician Assistants
• Nurse Practitioners
• Surgeons
• Hospitals and Other Facilities
• Insurance Companies
• Healthcare Consultants
• Practice Manager
• In and Out of Network Providers
• Medical Billing Companies
• Providers Office Staff
• Chief Compliance Officers
• Medical Providers
• Attorneys and Legal Staff
• Customer Service Managers
• Risk Managers

About the Presenter:

Thomas J. Force, ESQ., is a state and federally licensed attorney with over 34 years of experience in the healthcare and insurance industries. As a former U.S. Marine and a successful Wall Street insurance litigator, Mr. Force served as General Counsel for a New York-based Accident and Health Insurance Company, where he also served as Chief Compliance Officer. These experiences led to the founding of The Patriot Group.

Mr. Force is a nationally recognized expert in revenue collection techniques, appeal strategies, and healthcare compliance. He is on the Advisory Board at Hunter Business School, a New York-based school for medical billing and coding students.

Mr. Force is an active member and frequent speaker on managed care and collection techniques for the Health Finance Management Association, several state medical associations, and other healthcare organizations.

On March 29th, 2022, Thomas J. Force, J.D, ESQ., President of The Patriot Group, served as moderator for the forum on Clinical Denial Management at Hofstra University, organized by the Health Finance Management Association – Metropolitan Section.

Additional Information

Snippets From Our Previous Session