Reimbursement Page
Spreading the Holiday Cheer
By Joe McTernan, AOPA Director of Reimbursement Services
As the holiday season approaches, the inevitable questions arise
regarding gift-giving. In our personal lives, we wonder: Do I buy
jewelry for the person I have only been dating for a few months, or do
I take the safe route and buy a nice sweater? Does anyone really eat
fruitcake? Am I spoiling my children by getting them too many presents?
While these personal questions have no correct answers, there are very
specific rules that govern gift-giving in health care. This
month’s “Reimbursement Page” will discuss what is
allowed, what is not allowed, and the different restrictions on gifts
for patients and for referral sources.
Gifts to Medicare patients
The value of the patient/practitioner relationship is immeasurable.
There are very few situations that cannot be resolved if there is
mutual trust between an O&P practitioner and his patient. It is
natural, therefore, for providers to want to express their gratitude
toward their patients, especially around the holiday season.
While giving gifts to Medicare beneficiaries is allowed, the Social
Security Act contains several provisions that prohibit using gifts to
encourage patients to choose you over other providers in your area.
In August 2002, the Office of Inspector General (OIG) for the
Department of Health and Human Services (DHHS) published a special
fraud alert that set guidelines on acceptable gifts that providers can
offer to Medicare beneficiaries.
Cash gifts
Gifts of cash, or cash equivalents, are prohibited. Cash equivalents
include things like the routine waiver of coinsurance and deductibles,
gift certificates and gift cards.
An important exception to this rule is the waiver of coinsurance and
deductibles in cases where the patient is unable to pay. If this
scenario exists, providers may make case-by-case decisions to waive the
patient’s coinsurance and/or deductible. This decision should be
documented in your records.
While you are not required to take extreme measures to document the
patient’s overall financial indigence (e.g., tax returns, pay
stubs, etc.), you should document that you have reason to believe that
the patient cannot afford his deductible or coinsurance and that you
have made an individual decision to waive his financial responsibility.
Non-monetary gifts
Non-monetary gifts to Medicare beneficiaries are acceptable within
certain guidelines. The primary restriction on gifts to Medicare
beneficiaries is that they must be of nominal value. The OIG states
that the value of gifts to beneficiaries should not exceed $10 per gift
or $50 aggregate per calendar year. This means that you can offer a
Medicare beneficiary a maximum of five gifts valued at $10 in any
calendar year.
The OIG states specifically that there cannot be terms associated with
the gift. For example, you cannot require that the patient come in for
an evaluation in order to receive their gift. The low value limit on
gifts to beneficiaries allows you to show your appreciation for your
patients’ past business while steering clear of any potential
fraud and abuse allegations.
Gifts to referral sources
While providing gifts to Medicare beneficiaries should be approached
with caution, providing gifts to referral sources can be an even
stickier wicket. Federal anti-kickback provisions address limits on
gifts to referral sources.
As is the case with gifts to beneficiaries, monetary gifts of any value
are completely prohibited. Non-monetary gifts are allowed under very
limited circumstances. When originally published in 2004, the limit on
non-monetary gifts to referral sources was $300 per calendar year. This
limit is increased annually according to
the increase in the Consumer Price Index. The aggregate limit for 2007
is $329. In addition to the value limit on non-monetary gifts to
referral sources, several other restrictions govern the provision of
gifts to referral sources:
- The value of the gift may not be tied to the volume of referrals received from a physician’s office. For example, you cannot provide a gift of higher value to your regular referral sources than you do to practices that only refer patients periodically. While you do not have to offer an identical gift to each of your referral sources, you cannot base your decision on the number of referrals you receive.
- Referral sources may not solicit gifts. If a physician’s office requests a specific gift and you provide it, the OIG considers this an inducement to give future referrals.
In addition to federal anti-kickback provisions, the American Medical
Association has specific guidelines in its publication Gifts to
Physicians from Industry. This document, found at
www.ama-assn.org/ama/pub/category/5689.html, lists several guidelines
that physicians should use when determining when to accept a gift from
industry representatives for marketing purposes.
While not as binding as the federal anti-kickback laws, following these
guidelines as the gift giver will help to avoid any accusation of
impropriety. Three of the seven guidelines outline relatively simple
ways to provide gifts to referral sources with minimal exposure to
anti-kickback provisions:
-
Any gift should ideally provide a benefit to the patient as well as to the physician and should not be of substantial value.
-
Minimal gifts are permitted as long as they are related to the
physician’s work. These types of gifts include pens, prescription
pads and educational in-services.
-
As with patient gifts, there should be no strings attached to your gift-giving.
While giving gifts to Medicare beneficiaries and referral sources is
not a new business practice, reviewing and following the rules that
govern the process will help you enjoy the holiday season without worry.
| To Participate or Not to Participate? |
|
Now is the time of year to decide if you want to be a Medicare
participating provider for 2008. As with open enrollment for your
healthcare insurance, if you do not elect a different participation
status prior to December 31, 2007, you will be tied to your current
participation status for all of 2008. You do not have to be a participating provider in order to accept assignment on Medicare claims. Non-participating providers can make claim-by-claim decisions regarding assignment. For O&P providers, the only advantage to Medicare participation is publication in the annual Medicare participating provider directory. While physicians and other providers reimbursed under the physician fee schedule receive a 5 percent reimbursement premium if they elect to participate, there is no financial incentive for DMEPOS providers to participate in the Medicare program. The ultimate decision regarding Medicare participation should be made according to the best interests of your business, but must be made no later than December 31, 2007. |
For more information, contact Joe McTernan at (571) 431-0876, ext. 211, or jmcternan@aopanet.org.
