DRG Coding Advisor-Charity can bring its own punishment

OIG has providers worried about copays

Concerns by the Office of the Inspector General (OIG) that the unusual charitable practices of a few providers and ambulance services could be considered illegal has many providers worried that they could be busted for occasionally waiving copayments for poorer patients.

"Not to worry," says OIG spokeswoman Alwyn Cassil. The OIG does not plan any kind of organized investigation into copay waiver practices, she promises.

Providers are permitted under Medicare Part B to waive copayments once they have made a good faith effort to determine financial condition of a beneficiary. The OIG was concerned that routine waiver of copayments could be associated with more serious violations of reimbursement rules.

An objective standard

When considering a workable definition of financial hardship to justify waiving a copay, "I recommend my clients use an objective standard, preferably one set by another entity," notes health care lawyer Mike Carlson of Carlson and Associates in Birmingham, AL.

"For example, I have clients who have used their state's Medicaid eligibility standard. Others have used the food stamp program's standards and the federal poverty guidelines," he notes. The financial hardship line starts to blur, however, when it comes to what could be considered a temporary situation resulting from an unusual personal circumstance such as divorce, loss of a job, or catastrophic illness.