Billing Insurance Companies for Services · • The insurance company, through Leela’s health...

1Sep-18

College of Audiologists and Speech Language Pathologists of Ontario

Billing Insurance Companies for Services

September 19th 2018

2Sep-18

Alexandra Carling

Director of Professional Practice and Quality Assurance

Preeya Singh

Director of Professional Conduct and General Counsel

3Sep-18

Presentation focus

Providing invoices to patients and families who will access third party insurance company funding

Agenda

• Current Resources

• Background, Roles and Responsibilities

• Invoices

• Use of support personnel

• Who is the patient?

• Inappropriate and fraudulent claims

• Insurance Company concerns and strategies

• Questions

4Sep-18

Resources for developing invoices

5Sep-18

What documents do we

have to help you?

✓ Regulated Health Professions Act (RHPA)

✓ Personal Health Information Protection Act (PHIPA)

✓ Professional Misconduct Regulation

✓ Practice Advice articles

✓ Code of Ethics

✓ Records Regulation

6Sep-18

Where are they?

7Sep-18

Where are they?

8Sep-18

Background

• There are more than 13 million Canadian workers covered by employer-sponsored health benefit plans

• Adding families, it is estimated that over 25 million Canadians use employer-sponsored health benefit plans.

Canadian Life and Health Insurance Association (CLHIA) May 2018

9Sep-18

Not all plans cover speech language pathology and audiology services

10Sep-18

Patient and Family Responsibilities

It is the patient’s or family member’s responsibility to research their employer health benefit plan.

They are the plan’s recipients.

11Sep-18

Patient and Family Responsibilities

Plan recipients need to know the following:

✓ SLP & audiology services coverage

✓ Any restrictions to services

✓ Support personnel (CDA) coverage

✓ How much is covered per year

✓ Anniversary date of the health benefit plan

12Sep-18

Patient and Family Responsibilities

Patients and families must submit truthful claims

13Sep-18

SLP and Audiologist Roles and Responsibilities

14Sep-18

SLP and Audiologist Responsibilities

Records Regulation

15Sep-18

SLP and Audiologist Responsibilities

Patient financial records

33. (1) Subject to subsection (2), every member shall maintain a financial record for each patient that contains the following information regardless of whether the member bills the patient directly for professional products or services provided to the patient or bills a third party.

Next slide for list of items . . .

16Sep-18

SLP and Audiologist Responsibilities

Patient financial records must contain:

1. The patient’s name.

2. The member’s name.

3. If the person who provided the professional product or service was not the member, the name of that person.

4. Each professional product or service provided to the patient and the date it was provided.

5. The fee charged or received that relates to each professional product or service provided to the patient.

6. The total fee charged or received for all of the professional products or services.

7. A record of the receipt given by or on behalf of the member, if available. Records Regulation 33.(1)

17Sep-18

SLP and Audiologist Responsibilities

A copy of the invoice, as long as it includes all of the required information, can be the financial record

18Sep-18

Invoices

19Sep-18

Polling Question

20Sep-18

Jen is providing speech

services to Mia

• Mia’s next appointment is June 28th

• Mia’s mom asks Jen to change the date on the invoice to July 1st so she can access employer health benefits which start on July 1st

21Sep-18

Polling Question

Can Jen change the date on the invoice?

22Sep-18

Polling Question

1. Yes, she is still providing the session, it’s just a change of date to help Mia’s mom

2. No, the date on the invoice must match the date of the therapy session

3. Maybe, Jen has attended a presentation on ‘family-centred therapy’. Helping Mia’s mom could be viewed as a family centred approach

23Sep-18

Polling Answer

1. Yes, she is still providing the session, it’s just a change of date to help Mia’s mom

2. No, the date on the invoice must match the date of the session

3. Maybe, Jen has attended a presentation on ‘family-centred therapy’. Helping Max’s mom could be viewed as a family centred approach

24Sep-18

Second scenario

25Sep-18

Steven is prescribing and dispensing a hearing aid to one of his patients.

He is currently advertising and offering free hearing assessments.

Olivia, the patient, tells Steven that her employer’s health benefit plan covers hearing aids and services.

26Sep-18

Polling Question

Can Steven include the cost of the hearing assessment

on the invoice?

27Sep-18

Polling Question

1. Yes, Olivia’s health benefit plan will pay so it’s ok to charge for the assessment

2. Maybe, as Olivia’s plan is paying for hearing aid services, the cost of the assessment could be rolled into the final price on the invoice

3. No, Steven’s advertisement stated a free hearing assessment. It doesn’t matter who is paying for the hearing aid, the assessment must be free

28Sep-18

Polling Question

1. Yes, Olivia’s health benefit plan will pay so it’s ok to charge for the assessment

2. Maybe, as Olivia’s plan is paying for hearing aid services, the cost of the assessment could be rolled into the final price on the invoice

3. No, Steven’s advertisement stated a free hearing assessment. It doesn’t matter who is paying for the hearing aid, the assessment must be free

29Sep-18

SLP and Audiologist Responsibilities

• Be honourable and truthful in

all professional relations

Code of Ethics – Article 4.1.3

• Must not

Submit an account or charge

for services that the member knows is knows is false or misleading

Professional Misconduct Regulation (23)

30Sep-18

Patient and Family Pressure

31Sep-18

Patient and Family pressure

• Be strong . . .

• Don’t succumb to patient or family pressure

32Sep-18

Patient and Family pressure

Don’t . . .

x Falsify an invoice

x Alter the date of service provided

x Misrepresent who received the service

x Falsify the fee charged

33Sep-18

Creating invoices for other professionals

34Sep-18

Creating invoices for other professionals

Other professionals who are not covered by third party funders, e.g. HIPs and ABA therapists may approach you and ask you to develop an invoice to bill their time under your name.

35Sep-18

Be transparent about your fee structure on your invoice. What services do they include?

36Sep-18

Does your fee structure include:

• Preparation?

• A report?

• Travel?

• Referrals and communications with other professionals?

• Case conferences?

• Legal proceedings?

37Sep-18

Use of Support Personnel

38Sep-18

Polling Question

39Sep-18

Use of Support Personnel

Olga is a CDA working with Eloise, an audiologist

Olga is working with Wayne whohas had a cochlear implant

Eloise is supervising Olga

40Sep-18

Use of Support Personnel

Eloise, provides an invoice for the parentswhich they are submitting to their employer’shealth insurance plan

Eloise is not sure whose name should be included as the provider. Olga carries out the sessions, but Eloise has been providing her much support

41Sep-18

Polling Question

Whose name should be on the invoice as the service provider?

or

Eloise Olga

42Sep-18

Polling Question

1. Olga, she provided the service to Wayne

2. Eloise, she has spent much time and effort in meeting with Olga after the sessions to find out how therapy is going and plan for the next session

3. Eloise, Wayne’s dad may not get reimbursed from the insurance company if an unregulated professional is the service provider

43Sep-18

Polling Answer

1. Olga, she provided the service to Wayne

2. Eloise, she has spent much time and effort in meeting with Olga after the sessions to find out how therapy is going and plan for the next session

3. Eloise, Wayne’s dad may not get reimbursed from the insurance company if an unregulated professional is the service provider

44Sep-18

Use of Support Personnel

If support personnel (CDA) provided the service you must include that information on your invoice.

Don’t use an audiologist’s or SLP’s name and registration number on an invoice when support personnel provided the service.

It is up to Wayne’s dad to ask the insurance company if support personnel (CDA) service is covered.

45Sep-18

Use of Support Personnel

However, if you are directly supervising the support personnel’s session either in person or in real time via skype etc., you can include your name on the invoice as well as the support personnel’s name.

46Sep-18

Use of Support Personnel

Please refer to OSLA’s

guidelines regarding

Audiology, SLP and

support personnel

(CDA) recommended

hourly rates.

https://www.osla.on.ca/

47Sep-18

Who is the Patient?

48Sep-18

Polling Question

49Sep-18

Who is the Patient?

Sai has been referred to you for SLP services.

He has a diagnosis of autism and

you are providing communication

therapy

You provide a communication training session to Sai’s mom, Leela. Leela asks you to put her name on the invoice

50Sep-18

Who is the Patient?

For the communication training session, who is the patient?

Sai or Leela

51Sep-18

Polling Question

1. Unsure

2. Leela

3. Sai

52Sep-18

Polling Answer

1. Unsure

2. Leela

3. Sai

53Sep-18

Who is the Patient?

• Sai is your patient

• Leela is not your patient

• But, Leela received your services (communication

training) to better interact with Sai

• Your invoice must reflect who the patient is and

the service provided

54Sep-18

Who is the Patient?

• The insurance company, through Leela’s health benefit plan, may or may not pay for the parent education session

• It is up to the parent to find out if they are covered for education and training sessions

55Sep-18

Fraudulent submissions to health benefit plans by patients and families

56Sep-18

Fraudulent submissions

Beware! members of the public are occasionally using SLPs and audiologists’ names and registration numbers to make fraudulent claims to health benefit plans for service.

57Sep-18

Fraudulent submissions

• Contact the Insurance Bureau of Canada (IBC) at 1-877-IBC-TIPS

• For more information, please visit the insurance crime section of IBC’s website at www.ibc.ca.

58Sep-18

Fraudulent submissions

CASLPO recently received concerns that a member of the public was contacting SLPs in private practice for potentially fraudulent purposes.

The scenario: – SLPs contacted by an individual via email

– the individual is inquiring about the possibility of assessments and therapy sessions for four children

– the individual requests information about credit card payment options, and

– the individual does not provide a phone number or verifiable identifiers

59Sep-18

Fraudulent submissions

Credit Card Fraud? – This may have been a situation in which an individual

typically pre-pays for therapy sessions by credit card

– Then they request a refund before the payment is processed

– The initial credit card payment is subsequently declined, but the SLP has already paid out the requested refund, leaving the SLP out-of-pocket.

Similar fraudulent situations have been reported in the United States.

60Sep-18

Inappropriate billing by Companies

61Sep-18

Inappropriate billing by Companies

• Members have contacted the College because they suspect that a private company they work for has incorrectly invoiced patients and families.

• Is this a mistake? In most cases, the invoicing error was not intentional. Have a conversation with your manager or the person sending out the invoice.

• Take corrective action – advise contacting the family and sending a correct invoice.

• If it is pervasive behaviour, contact the College.

62Sep-18

Insurance Company Concerns and Strategies

63Sep-18

Unnecessary and excessive treatment

64Sep-18

Unnecessary and excessive treatment

Insurance companies have brought concerns to the College regarding unnecessary and excessive treatment, especially when the employee has unlimited SLP and audiology services in their health benefits plan.

Code of Ethics

Principle 1: The primary ethical obligation of audiologists and speech-language pathologists is to practice their skills for the benefit of their patients/clients.

65Sep-18

Unnecessary and excessive treatment

Professional Misconduct Regulation

paragraph 22

It is an act of professional misconduct to sign or issue, in the member’s professional capacity, a document that the member knows contains a false or misleading statement.

paragraph 23

It is an act of professional misconduct to submit an account or charge for services that the member knows is false or misleading

66Sep-18

Proposed Advertising Regulation

Draft - 2013

3. A communication by a member to a patient or client or prospective patient or client for the purposes of soliciting business shall be appropriate to the context and shall be respectful of patient or client choice, and not involve undue pressure and not promote unnecessary products or services.

67Sep-18

Unnecessary and excessive treatment

Professional Practice Standards: Self-Assessment Tool

1.1 I have criteria to begin and end intervention (intervention refers to screening, assessment and management).

2.3 I use intervention procedures based on current knowledge incorporating evidence based research and advances in technology.

2.6 I monitor, evaluate and modify my intervention procedures based on patient outcome.

68Sep-18

Insurance Companies Audits and Investigations

69Sep-18

Insurance companies will either randomly audit claims or investigate a potentially fraudulent claim.

Members should inform patients and families at the initial visit that every time they submit a health benefit claim, they are authorizing the insurance company to collect the following:

• The service provided, identifying

what the service was e.g.,

assessment, therapy, education etc. INVOICE

• Who provided the service INFO

• The date service was provided

• The amount invoiced for the service

70Sep-18

If the insurance company wishes to examine the patient record, then knowledgeable consent to disclose personal health information must be obtained from the patient and documented before you can disclose the patient record.

The insurance company can obtain knowledgeable consent on behalf of the patient, but then must provide the evidence of consent to the SLP or audiologist.

Only disclose what is specifically requested and consented to.

71Sep-18

Alexandra Carling Ph.D.Director of Professional Practice and Quality Assurance

T. 416-975-5347 Ext 226 Toll-Free (ON) 800-993-9459

acarling@caslpo.com

Preeya Singh, LL.B.Director of Professional Conduct & General Counsel

T. 416-975-5347 Ext 221 Toll-Free (ON) 800-993-9459

psingh@caslpo.com