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BUSINESS: Coding Strategy

Guidance on Fee Reduction

Office of Inspector General publishes policy statement for emergency declaration

One of the topics much discussed these days is the public health emergency declaration of Jan. 31 and its April 26 renewal by the secretary of Health and Human Services (which remains in effect for 90 days or until the secretary declares that it no longer exists) and how it affects our everyday practice of eye care (bit.ly/emergencyrenewal ).

One change of interest is the policy statement by the Office of the Inspector General (OIG) regarding routine reduction or waivers of costs to patients covered by federal health care programs.

GUIDELINES ON COPAYS

The OIG has created and enforced strict guidelines regarding physicians and other practitioners reducing or waiving amounts owed by federal health care program beneficiaries. Most private insurers follow the same guidelines (be sure to verify each plan’s policy individually). Ordinarily, the OIG policy states that reducing or waiving any cost-sharing obligations the beneficiary may have may potentially prompt:

  1. The federal anti-kickback statute;
  2. The civil monetary penalty and exclusion laws related to kickbacks;
  3. The civil monetary penalty law prohibition on inducements to beneficiaries.

WHAT’S NEW

On March 17 the OIG published this policy statement, which can be found at bit.ly/2VZKRT1 , that begins by stating the following [emphasis added]:

In response to the unique circumstances resulting from the outbreak of 2019 novel coronavirus (COVID-19) and the Secretary’s January 31, 2020, determination, pursuant to section 319 of the Public Health Service Act, that a public health emergency exists and has existed since January 27, 2020 (COVID-19 Declaration), the Office of Inspector General (OIG) issues this Policy Statement to notify physicians and other practitioners that they will not be subject to administrative sanctions for reducing or waiving any cost-sharing obligations Federal health care program beneficiaries may owe for telehealth services furnished consistent with the then-applicable coverage and payment rules, subject to the conditions specified herein.

OIG is committed to protecting patients by ensuring that healthcare providers have the regulatory flexibility necessary to adequately respond to COVID-19 concerns.

Ordinarily, routine reductions or waivers of costs owed by Federal health care program beneficiaries, including cost-sharing amounts such as coinsurance and deductibles, potentially implicate the Federal anti-kickback statute, the civil monetary penalty and exclusion laws related to kickbacks, and the civil monetary penalty law prohibition on inducements to beneficiaries. Nonetheless, recognizing the unique circumstances resulting from the COVID-19 outbreak, OIG will not subject physicians and other practitioners to OIG administrative sanctions for arrangements that satisfy both of the following conditions:

  1. A physician or other practitioner reduces or waives cost-sharing obligations (i.e., coinsurance and deductibles) that a beneficiary may owe for Telehealth services furnished consistent with the then-applicable coverage and payment rules.
  2. The Telehealth services are furnished during the time period subject to the COVID-19 Declaration.

CALL INSURANCE COMPANIES

Some insurance plans are paying patient co-pays at this time; however the only way to be certain of each plan’s guidelines is to call and verify for each patient. The rules change as the situation changes. Keep insurance plan links handy, educate your team, and beware that when the public health emergency is over the rules will revert back. OM