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CMECNE

Waive the Copay and Wave Hello to Potential Legal Penalties

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Explain how waiving a copay may make you vulnerable under anti-kickback laws
2. Describe how ERISA laws can be used against providers who waive insurance payments that are a patient’s responsibility

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

To help out their patients burdened by healthcare costs, providers may on occasion consider not collecting copayments and deductibles. The patient may claim financial distress. Or the amount may not seem worth pursuing, although $20 or more per patient quickly adds up over the course of a year. Routinely waiving copays, however, makes you vulnerable to charges under the federal False Claims Act, as well as the federal antikickback law and similar state laws. And you risk fines of up to $25,000 and possible exclusion from federal insurance programs for violating the federal antikickback law alone.

Except in limited circumstances, Medicare and Medicaid don’t allow such waivers and demand that providers collect those amounts from patients. Routinely waiving them can be interpreted as program abuse. Why? Because a claim to government programs for patients in which a copayment or deductible was waived is misrepresenting the true charge for service.  And there’s more. Rather than being perceived as the kindhearted person that you are, not collecting these payments can make it appear as if you are trying to attract patients by offering something of value, and consequently generating Medicaid or Medicare payments – a violation of the antikickback law.

If the patient has private insurance, you could be giving the patient’s insurer an opening to escape paying its share of your bill. For example, assume there is a $100 total charge where the patient has an 80/20 plan.  If the provider waives the patient’s obligation to pay 20%, then, again arguably, the commercial plan owes only 80% of $80.

Be especially wary of copays. The rules of managed care are federally mandated and clearly state that the patient cannot see the doctor until they make their copayment. Many providers will recognize this clause in their contracts with insurance companies. Health insurance (including commerical) is also governed by a set of federal laws that fall under ERISA (The Employee Retirement Income Security Act). Commercial insurers can claim that the doctor interfered with their contracts with employers/individuals and some insurance companies have been aggressively fighting back on this front, including using the courts.  Therefore, the safest course is simply to avoid granting copay waivers.  If a patient has a true well-defined financial hardship, document the situation and in isolated, worthy cases, there is the option of reducing a deductible.

Ultimately, regardless of how onerous or convoluted insurance plans are, the responsibility for these payments rests with the patient as conceptually, they have entered into a ‘cost sharing’ arrangement with the company or organization that is providing their healthcare coverage.

RESOURCES:

Failure to collect copayments or deductibles for a specific group of Medicare patients

$5.31 Million Civil Settlement Against Hematology-Oncology Medical Practice For Submitting False Claims To Medicare And Medicaid

AAFP: Anti-kickback & Stark Compliance

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This website (the “Website”) is a service made available by The ObG Project LLC, its partners, affiliates or subsidiaries (“Provider”). This Website provides general information related to the law and is designed to help users safely cope with their own legal needs. This website does not provide legal advice and Provider is not a law firm. None of our customer service representatives are lawyers and they also do not provide legal advice. Although we go to great lengths to make sure our information is accurate and useful, we recommend you consult a lawyer if you want legal advice. No attorney-client or confidential relationship exists or will be formed between you and Provider or any of our representatives.
This website is not intended to be a source for legal advice, and thus the reader should not rely on any information provided in this website as such. Readers should not consider the information provided to be an invitation for an attorney-client relationship, and should always seek the advice of competent counsel in the reader’s home jurisdiction. Provider may provide links to third party websites. These links are provided only as a convenience. Linked websites are not reviewed, controlled or examined by Provider and Provider is not responsible for the information, advertising, products, resources or other materials, of any linked site or any link contained in a linked site. The inclusion of any link does not imply endorsement by Provider. In addition, please be aware that your use of any linked site is subject to the terms and conditions applicable to that site. Please direct any questions regarding linked sites to the webmaster of that site.
Courtesy Mahdi Weinstock LLP, Toronto CA

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

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This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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