billing insurance companies for services · • the insurance company, through leela’s health...
TRANSCRIPT
1Sep-18
College of Audiologists and Speech Language Pathologists of Ontario
Billing Insurance Companies for Services
September 19th 2018
2Sep-18
Alexandra Carling
Director of Professional Practice and Quality Assurance
Preeya Singh
Director of Professional Conduct and General Counsel
3Sep-18
Presentation focus
Providing invoices to patients and families who will access third party insurance company funding
Agenda
• Current Resources
• Background, Roles and Responsibilities
• Invoices
• Use of support personnel
• Who is the patient?
• Inappropriate and fraudulent claims
• Insurance Company concerns and strategies
• Questions
4Sep-18
Resources for developing invoices
5Sep-18
What documents do we
have to help you?
✓ Regulated Health Professions Act (RHPA)
✓ Personal Health Information Protection Act (PHIPA)
✓ Professional Misconduct Regulation
✓ Practice Advice articles
✓ Code of Ethics
✓ Records Regulation
6Sep-18
Where are they?
7Sep-18
Where are they?
8Sep-18
Background
• There are more than 13 million Canadian workers covered by employer-sponsored health benefit plans
• Adding families, it is estimated that over 25 million Canadians use employer-sponsored health benefit plans.
Canadian Life and Health Insurance Association (CLHIA) May 2018
9Sep-18
Not all plans cover speech language pathology and audiology services
10Sep-18
Patient and Family Responsibilities
It is the patient’s or family member’s responsibility to research their employer health benefit plan.
They are the plan’s recipients.
11Sep-18
Patient and Family Responsibilities
Plan recipients need to know the following:
✓ SLP & audiology services coverage
✓ Any restrictions to services
✓ Support personnel (CDA) coverage
✓ How much is covered per year
✓ Anniversary date of the health benefit plan
12Sep-18
Patient and Family Responsibilities
Patients and families must submit truthful claims
13Sep-18
SLP and Audiologist Roles and Responsibilities
14Sep-18
SLP and Audiologist Responsibilities
Records Regulation
15Sep-18
SLP and Audiologist Responsibilities
Patient financial records
33. (1) Subject to subsection (2), every member shall maintain a financial record for each patient that contains the following information regardless of whether the member bills the patient directly for professional products or services provided to the patient or bills a third party.
Next slide for list of items . . .
16Sep-18
SLP and Audiologist Responsibilities
Patient financial records must contain:
1. The patient’s name.
2. The member’s name.
3. If the person who provided the professional product or service was not the member, the name of that person.
4. Each professional product or service provided to the patient and the date it was provided.
5. The fee charged or received that relates to each professional product or service provided to the patient.
6. The total fee charged or received for all of the professional products or services.
7. A record of the receipt given by or on behalf of the member, if available. Records Regulation 33.(1)
17Sep-18
SLP and Audiologist Responsibilities
A copy of the invoice, as long as it includes all of the required information, can be the financial record
18Sep-18
Invoices
19Sep-18
Polling Question
20Sep-18
Jen is providing speech
services to Mia
• Mia’s next appointment is June 28th
• Mia’s mom asks Jen to change the date on the invoice to July 1st so she can access employer health benefits which start on July 1st
21Sep-18
Polling Question
Can Jen change the date on the invoice?
22Sep-18
Polling Question
1. Yes, she is still providing the session, it’s just a change of date to help Mia’s mom
2. No, the date on the invoice must match the date of the therapy session
3. Maybe, Jen has attended a presentation on ‘family-centred therapy’. Helping Mia’s mom could be viewed as a family centred approach
23Sep-18
Polling Answer
1. Yes, she is still providing the session, it’s just a change of date to help Mia’s mom
2. No, the date on the invoice must match the date of the session
3. Maybe, Jen has attended a presentation on ‘family-centred therapy’. Helping Max’s mom could be viewed as a family centred approach
24Sep-18
Second scenario
25Sep-18
Steven is prescribing and dispensing a hearing aid to one of his patients.
He is currently advertising and offering free hearing assessments.
Olivia, the patient, tells Steven that her employer’s health benefit plan covers hearing aids and services.
26Sep-18
Polling Question
Can Steven include the cost of the hearing assessment
on the invoice?
27Sep-18
Polling Question
1. Yes, Olivia’s health benefit plan will pay so it’s ok to charge for the assessment
2. Maybe, as Olivia’s plan is paying for hearing aid services, the cost of the assessment could be rolled into the final price on the invoice
3. No, Steven’s advertisement stated a free hearing assessment. It doesn’t matter who is paying for the hearing aid, the assessment must be free
28Sep-18
Polling Question
1. Yes, Olivia’s health benefit plan will pay so it’s ok to charge for the assessment
2. Maybe, as Olivia’s plan is paying for hearing aid services, the cost of the assessment could be rolled into the final price on the invoice
3. No, Steven’s advertisement stated a free hearing assessment. It doesn’t matter who is paying for the hearing aid, the assessment must be free
29Sep-18
SLP and Audiologist Responsibilities
• Be honourable and truthful in
all professional relations
Code of Ethics – Article 4.1.3
• Must not
Submit an account or charge
for services that the member knows is knows is false or misleading
Professional Misconduct Regulation (23)
30Sep-18
Patient and Family Pressure
31Sep-18
Patient and Family pressure
• Be strong . . .
• Don’t succumb to patient or family pressure
32Sep-18
Patient and Family pressure
Don’t . . .
x Falsify an invoice
x Alter the date of service provided
x Misrepresent who received the service
x Falsify the fee charged
33Sep-18
Creating invoices for other professionals
34Sep-18
Creating invoices for other professionals
Other professionals who are not covered by third party funders, e.g. HIPs and ABA therapists may approach you and ask you to develop an invoice to bill their time under your name.
35Sep-18
Be transparent about your fee structure on your invoice. What services do they include?
36Sep-18
Does your fee structure include:
• Preparation?
• A report?
• Travel?
• Referrals and communications with other professionals?
• Case conferences?
• Legal proceedings?
37Sep-18
Use of Support Personnel
38Sep-18
Polling Question
39Sep-18
Use of Support Personnel
Olga is a CDA working with Eloise, an audiologist
Olga is working with Wayne whohas had a cochlear implant
Eloise is supervising Olga
40Sep-18
Use of Support Personnel
Eloise, provides an invoice for the parentswhich they are submitting to their employer’shealth insurance plan
Eloise is not sure whose name should be included as the provider. Olga carries out the sessions, but Eloise has been providing her much support
41Sep-18
Polling Question
Whose name should be on the invoice as the service provider?
or
Eloise Olga
42Sep-18
Polling Question
1. Olga, she provided the service to Wayne
2. Eloise, she has spent much time and effort in meeting with Olga after the sessions to find out how therapy is going and plan for the next session
3. Eloise, Wayne’s dad may not get reimbursed from the insurance company if an unregulated professional is the service provider
43Sep-18
Polling Answer
1. Olga, she provided the service to Wayne
2. Eloise, she has spent much time and effort in meeting with Olga after the sessions to find out how therapy is going and plan for the next session
3. Eloise, Wayne’s dad may not get reimbursed from the insurance company if an unregulated professional is the service provider
44Sep-18
Use of Support Personnel
If support personnel (CDA) provided the service you must include that information on your invoice.
Don’t use an audiologist’s or SLP’s name and registration number on an invoice when support personnel provided the service.
It is up to Wayne’s dad to ask the insurance company if support personnel (CDA) service is covered.
45Sep-18
Use of Support Personnel
However, if you are directly supervising the support personnel’s session either in person or in real time via skype etc., you can include your name on the invoice as well as the support personnel’s name.
46Sep-18
Use of Support Personnel
Please refer to OSLA’s
guidelines regarding
Audiology, SLP and
support personnel
(CDA) recommended
hourly rates.
https://www.osla.on.ca/
47Sep-18
Who is the Patient?
48Sep-18
Polling Question
49Sep-18
Who is the Patient?
Sai has been referred to you for SLP services.
He has a diagnosis of autism and
you are providing communication
therapy
You provide a communication training session to Sai’s mom, Leela. Leela asks you to put her name on the invoice
50Sep-18
Who is the Patient?
For the communication training session, who is the patient?
Sai or Leela
51Sep-18
Polling Question
1. Unsure
2. Leela
3. Sai
52Sep-18
Polling Answer
1. Unsure
2. Leela
3. Sai
53Sep-18
Who is the Patient?
• Sai is your patient
• Leela is not your patient
• But, Leela received your services (communication
training) to better interact with Sai
• Your invoice must reflect who the patient is and
the service provided
54Sep-18
Who is the Patient?
• The insurance company, through Leela’s health benefit plan, may or may not pay for the parent education session
• It is up to the parent to find out if they are covered for education and training sessions
55Sep-18
Fraudulent submissions to health benefit plans by patients and families
56Sep-18
Fraudulent submissions
Beware! members of the public are occasionally using SLPs and audiologists’ names and registration numbers to make fraudulent claims to health benefit plans for service.
57Sep-18
Fraudulent submissions
• Contact the Insurance Bureau of Canada (IBC) at 1-877-IBC-TIPS
• For more information, please visit the insurance crime section of IBC’s website at www.ibc.ca.
58Sep-18
Fraudulent submissions
CASLPO recently received concerns that a member of the public was contacting SLPs in private practice for potentially fraudulent purposes.
The scenario: – SLPs contacted by an individual via email
– the individual is inquiring about the possibility of assessments and therapy sessions for four children
– the individual requests information about credit card payment options, and
– the individual does not provide a phone number or verifiable identifiers
59Sep-18
Fraudulent submissions
Credit Card Fraud? – This may have been a situation in which an individual
typically pre-pays for therapy sessions by credit card
– Then they request a refund before the payment is processed
– The initial credit card payment is subsequently declined, but the SLP has already paid out the requested refund, leaving the SLP out-of-pocket.
Similar fraudulent situations have been reported in the United States.
60Sep-18
Inappropriate billing by Companies
61Sep-18
Inappropriate billing by Companies
• Members have contacted the College because they suspect that a private company they work for has incorrectly invoiced patients and families.
• Is this a mistake? In most cases, the invoicing error was not intentional. Have a conversation with your manager or the person sending out the invoice.
• Take corrective action – advise contacting the family and sending a correct invoice.
• If it is pervasive behaviour, contact the College.
62Sep-18
Insurance Company Concerns and Strategies
63Sep-18
Unnecessary and excessive treatment
64Sep-18
Unnecessary and excessive treatment
Insurance companies have brought concerns to the College regarding unnecessary and excessive treatment, especially when the employee has unlimited SLP and audiology services in their health benefits plan.
Code of Ethics
Principle 1: The primary ethical obligation of audiologists and speech-language pathologists is to practice their skills for the benefit of their patients/clients.
65Sep-18
Unnecessary and excessive treatment
Professional Misconduct Regulation
paragraph 22
It is an act of professional misconduct to sign or issue, in the member’s professional capacity, a document that the member knows contains a false or misleading statement.
paragraph 23
It is an act of professional misconduct to submit an account or charge for services that the member knows is false or misleading
66Sep-18
Proposed Advertising Regulation
Draft - 2013
3. A communication by a member to a patient or client or prospective patient or client for the purposes of soliciting business shall be appropriate to the context and shall be respectful of patient or client choice, and not involve undue pressure and not promote unnecessary products or services.
67Sep-18
Unnecessary and excessive treatment
Professional Practice Standards: Self-Assessment Tool
1.1 I have criteria to begin and end intervention (intervention refers to screening, assessment and management).
2.3 I use intervention procedures based on current knowledge incorporating evidence based research and advances in technology.
2.6 I monitor, evaluate and modify my intervention procedures based on patient outcome.
68Sep-18
Insurance Companies Audits and Investigations
69Sep-18
Insurance companies will either randomly audit claims or investigate a potentially fraudulent claim.
Members should inform patients and families at the initial visit that every time they submit a health benefit claim, they are authorizing the insurance company to collect the following:
• The service provided, identifying
what the service was e.g.,
assessment, therapy, education etc. INVOICE
• Who provided the service INFO
• The date service was provided
• The amount invoiced for the service
70Sep-18
If the insurance company wishes to examine the patient record, then knowledgeable consent to disclose personal health information must be obtained from the patient and documented before you can disclose the patient record.
The insurance company can obtain knowledgeable consent on behalf of the patient, but then must provide the evidence of consent to the SLP or audiologist.
Only disclose what is specifically requested and consented to.
71Sep-18
Alexandra Carling Ph.D.Director of Professional Practice and Quality Assurance
T. 416-975-5347 Ext 226 Toll-Free (ON) 800-993-9459
Preeya Singh, LL.B.Director of Professional Conduct & General Counsel
T. 416-975-5347 Ext 221 Toll-Free (ON) 800-993-9459
