Understanding health insurance reimbursement for Surgical Assistants

BILLING OVERVIEW FOR THE BILLING OVERVIEW FOR THE SURGICAL ASSISTANTSURGICAL ASSISTANT

Luis F. Aragon, RSASurgbill Inc.

Managed Care ModelsManaged Care ModelsExclusive provider organizations (EPO)Exclusive provider organizations (EPO)Integrated Delivery System (IDS)Integrated Delivery System (IDS)Health maintenance organizations (HMO)Health maintenance organizations (HMO) Direct Contract model Group Model Individual Practice Association Network model Staff model

Point of service plan (POS)Point of service plan (POS)Preferred Provider organization (PPO)Preferred Provider organization (PPO)Triple option planTriple option plan


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 accountsHigh deductible insurance policyDisadvantage 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.

CONSUMER DIRECTED HEALTH PLANS (CDHP)CONSUMER DIRECTED HEALTH PLANS (CDHP)


Clean claimClean claim


Life Cycle of an Insurance ClaimLife Cycle of an Insurance Claim


Terms to knowTerms to knowCoordination of Benefits (COB)Coordination of Benefits (COB)Non-covered benefits vs unauthorized servicesNon-covered benefits vs unauthorized servicesAllowed charges for the CPT in questionAllowed charges for the CPT in questionDeductibleDeductibleCo-insuranceCo-insuranceCo-paymentCo-paymentERA vs EOBERA vs EOB


Patients can be billed for non-covered procedures, Patients can be billed for non-covered procedures, but not for unauthorized services. Providers process but not for unauthorized services. Providers process denials of unauthorized services as a business loss.denials of unauthorized services as a business loss.Claims are adjudicated by line item (not for total Claims are adjudicated by line item (not for total charges), which means that payers bundle and edit charges), which means that payers bundle and edit code numbers for individual procedures and code numbers for individual procedures and services. Each payor may be different in their code services. Each payor may be different in their code edits. Payors are known for not applying official edits. Payors are known for not applying official coding guidelines for ICD-9 and CPT codes.coding guidelines for ICD-9 and CPT codes.The patient is responsible for co-payments and The patient is responsible for co-payments and deductibles, but does not pay more than the allowed deductibles, but does not pay more than the allowed negotiated rate.negotiated rate.

Facts to knowFacts to know


No Out of Network benefitsNo Out of Network benefits


Co-insuranceCo-insurance


No balance billing allowedNo balance billing allowed


DeductibleDeductible


Co-insuranceCo-insurance


To bill or not to bill! To bill or not to bill! (Patients)(Patients)

This is an issue of debate nationwide in the Surgical This is an issue of debate nationwide in the Surgical Assistant industry.Assistant industry.Facilities and surgeons want the advantage of our services Facilities and surgeons want the advantage of our services for free or for a minimal fee but do not want their patients for free or for a minimal fee but do not want their patients to be bothered with an additional bill.to be bothered with an additional bill.We recommend billing for deductibles and co-payments, but We recommend billing for deductibles and co-payments, but strongly advise against balance billing or when the plan strongly advise against balance billing or when the plan does not have out of network benefits.does not have out of network benefits.And even deductibles and co-payments fall in the out of And even deductibles and co-payments fall in the out of network category, you have to make sure that your network category, you have to make sure that your surgeons and facilities know that you are engaging in this surgeons and facilities know that you are engaging in this practice.practice.Facilities and surgeons prefer for us to be on the Facilities and surgeons prefer for us to be on the background much like the CRNAs, and this has worked as a background much like the CRNAs, and this has worked as a win-win situation for both parties, but what is going to win-win situation for both parties, but what is going to happen when CDHP plans start to take off?happen when CDHP plans start to take off?


Bottom LineBottom LineYour practice has to be prepared for the following Your practice has to be prepared for the following issues: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.


AMA Council on Ethics and AMA Council on Ethics and Judicial AffairsJudicial Affairs

Opinion Issued:Opinion Issued: The AMA has The AMA has acknowledged that routine waivers acknowledged that routine waivers of coinsurance/deductibles of coinsurance/deductibles constitutes fraud, and proclaims constitutes fraud, and proclaims the practice to be unethical. the practice to be unethical.


•http://www.ama-assn.org/ama/pub/category/4615.html

AMA Council on Ethics and AMA Council on Ethics and Judicial AffairsJudicial Affairs• Opinion 6.12 - Forgiveness or Opinion 6.12 - Forgiveness or

Waiver of Insurance Copayments:Waiver of Insurance Copayments:Physicians should be aware that Physicians should be aware that forgiveness or waiver of co-forgiveness or waiver of co-payments may violate the policies payments may violate the policies of some insurers, both public and of some insurers, both public and private….. Routine forgiveness or private….. Routine forgiveness or waiver of co-payments may waiver of co-payments may constitute fraud under state and constitute fraud under state and federal law.federal law.


HIPAA Section 242HIPAA Section 242(Public Law 104-191 104(Public Law 104-191 104thth Congress) Title II, Subtitle E Congress) Title II, Subtitle E

Whoever knowingly and willfully executes, or Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice-- attempts to execute, a scheme or artifice-- (1) to defraud any health care benefit (1) to defraud any health care benefit program; or (2) to obtain, by means of false program; or (2) to obtain, by means of false or fraudulent pretenses, representations, or or fraudulent pretenses, representations, or promises, any of the money or property promises, any of the money or property owned by, or under the custody or control owned by, or under the custody or control of, any health care benefit program, in of, any health care benefit program, in connection with the delivery of or payment connection with the delivery of or payment for health care benefits, items, or services, for health care benefits, items, or services, shall be fined under this title or imprisoned shall be fined under this title or imprisoned not more than 10 years, or both. not more than 10 years, or both.


Fraudulent & False Fraudulent & False StatementsStatements Professional courtesy discounts in the Professional courtesy discounts in the

form of a waiver of a co-payment or form of a waiver of a co-payment or deductible constitutes both health deductible constitutes both health care fraud and false statements.care fraud and false statements.

Knowing you are required to collect a Knowing you are required to collect a co-pay or deductible but billing co-pay or deductible but billing insurance only is committing health insurance only is committing health care fraud;care fraud;

By billing an insurance company one By billing an insurance company one charge but failing to collect the charge but failing to collect the patient co-pay or deductible, the patient co-pay or deductible, the provider is making a false statement provider is making a false statement regarding the charge.regarding the charge.


What Does OIG Say?What Does OIG Say?

In 1991 the Office of Inspector General In 1991 the Office of Inspector General (OIG) issued a fraud alert concerning (OIG) issued a fraud alert concerning the wavier of co-pays and the wavier of co-pays and deductibles. The OIG stated that deductibles. The OIG stated that billing billing ““insurance onlyinsurance only”” may violate may violate the False Claims Act, the Anti-the False Claims Act, the Anti-Kickback Statute, the Civil Monetary Kickback Statute, the Civil Monetary Penalties Law, 42 U.S.C sec 1320a-Penalties Law, 42 U.S.C sec 1320a-7a(a)(5), 7a(a)(5), as amendedas amended by Pub.L.No by Pub.L.No 104-91 sec 231 (h), and State laws.104-91 sec 231 (h), and State laws.



• Routine Waiver of Routine Waiver of Deductibles & Coinsurance Deductibles & Coinsurance ProhibitedProhibited

• 1994 Special Fraud Alert - 1994 Special Fraud Alert - http://oig.hhs.gov/fraud/docs/alertsandbulletins/121994.htmlhttp://oig.hhs.gov/fraud/docs/alertsandbulletins/121994.html

• 1991 Safe Harbor Regulations Alert – 1991 Safe Harbor Regulations Alert – • http://oig.hhs.gov/fraud/docs/safeharborregulations/072991.htm


http://oig.hhs.gov/fraud/docs/alertsandbulletins/121994.html

http://oig.hhs.gov/fraud/docs/safeharborregulations/072991.htm


• Waivers of Cost-Sharing Amounts For Waivers of Cost-Sharing Amounts For Financially needy Medicare & Medicaid Financially needy Medicare & Medicaid Patients Permitted:Patients Permitted:

1)1) Waiver must not be routine;Waiver must not be routine;2)2) Waivers may not be offered through Waivers may not be offered through

advertisement or solicitation;advertisement or solicitation;3)3) Waivers may only be offered after Waivers may only be offered after

determining in good faith that there is a determining in good faith that there is a financial need or when reasonable financial need or when reasonable collection efforts have failed collection efforts have failed


•See testimony, Lewis Morris, Chief Counsel to OIG, 2004 http://oig.hhs.gov/testimony/docs/2004/40624oig.pdf

What do I do then?What do I do then?

PROVIDE AN ABN (Advanced Beneficiary Notice) during the PROVIDE AN ABN (Advanced Beneficiary Notice) during the first visit to your surgeonfirst visit to your surgeon’’s office: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.

CYACYALuis F. Aragon, RSASurgbill Inc.

Questions?Questions?Luis F. Aragon, RSASurgbill Inc.

Health & Medicine

Understanding health insurance reimbursement for Surgical Assistants