Do
you think you understand the Maryland prohibition on
balance billing an HMO patient?
Most
groups do not....ask the Maryland Insurance
Administration!
Legislation
is going to be proposed that sanctions loss of medical
license if you violate the balance billing laws
Do
we have your attention now?
Preamble
In a educational
presentation sponsored by Med Chi, Maryland MGMA and the
Maryland Chapter of the AAPC, the Maryland Insurance
Administration (MIA) stunned the majority of the
attendees by proving that most groups do not know the
details of the balance billing laws for HMO patients
(19-710.1). Because of all of the complaints
against providers, in this upcoming legislative session,
a bill that enforces taking away physician licenses for
those who violate the law may be introduced. To
our clients and friends, take a minute to make sure you
are ready.
Issue #1
If a patient has coverage
under an HMO that is licensed in the State of Maryland,
ANY covered service may not be billed to the patient.
Response: Even
when a practice may not know that a patient is an HMO
patient (no card), it is a violation of the statute to
bill the patient for a service covered under the policy.
(Except for co-pays)
Issue #2
Nowhere in the current
statute does a consumer have an explicit option to
opt-out of an HMO plan and seek care on their own.
Response: There
is no provision for patients being able to sign waivers
for services to be provided on a self pay basis such as
when they present with no referral or for rarely covered
procedures. No waiver has been approved in
Maryland that allows patients without referrals to take
responsibility for bills that should be covered by
HMO's. Many practices do not know this is the
case. Each time a patient receives a bill, it is a
violation of Maryland Law.
Issue #3
The law has changed to
permit providers to opt out of multi-product
contracts.
Response:
No longer must providers accept all contracts with a
particular payer. Groups may elect to participate with a
PPO and not the HMO or an HMO and not the payers PPO.
You may want to revisit some of your payer agreements
that were signed in the past.
Issue #4
Maryland Law does not
require that insurers provide insurance cards.
Response:
Patients and groups cannot use an insurance card as
evidence of insurance coverage. If an insurer
provides a card, it is only as a courtesy.
Issue #5
It does not matter if you
are participating with the HMO or non participating with
the HMO. As long as the HMO is licensed in
Maryland, any billing of HMO patients is illegal.
Response:
Think about it. You cannot bill a HMO patient even
though you have no contractual relationship with that
company. You must accept what the HMO pays you as a
non-contracted provider and you may not balance bill the
patient. How do you know a patient is not an HMO
patient?
Issue #6
There is no standard
definition of "covered service".
Response:
One payer might assume that lack of a referral might
mean it is non-covered and billable to a patient and
another may say it is a covered but unpayable
service. Absent of a legislated definition, groups
are at the mercy of the payers definition.
Issue #7 and
Response:
These are serious issues in having services paid for
promptly. Support your professional
membership associations in addressing these issues.
So, how will a practice
respond? Feel free to send us your comments and if there
is anything that STATpay can do for you, please let us
know! |
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