Learning Objectives

• 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
  • NY – Penal Law Section – 177
  • NJ – N.J. Stat. 2A:32C
  • False Claims Act
  • Anti-Kickback Statute
  • State Laws
• 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
  • What constitutes a Good Faith Determination of “Financial Need”?
  • 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
  • Financial Hardship
  • OIG Safe Harbor
  • Professional Courtesy Discounts
  • Prompt Payment Discounts
• 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.)

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