Do:

• Follow CCO standards and Guidelines and keep accurate, thorough, and up-to- date clinical notes. See, in particular, CCO Standard of Practice S-002: Record Keeping.
• Ensure your website and social media accounts are consistent with CCO Standard of Practice S-016: Advertising.
• Understand what “loss leaders” and “incentives” are and why the insurance industry views “free” giveaways of non-nominal value (e.g. free shoes with Orthotics) as a form of Fraud.
• Understand insurers’ policies related to billing and receipts and ensure that you are following billing and receipts leading practices.
• Review every document that leaves the office with your license number on it.

Don’t:

• Submit an invoice indicating the patient paid for a service or product when they didn’t.
• Invoice for an amount that includes a Co-payment that you don’t intend to collect from the patient. Likewise, don’t issue a receipt that says the patient paid the co-payment when they didn’t.
• Submit an invoice indicating the patient paid for a service or product when they didn’t.
• Invoice for an amount that includes a co-payment that you don’t intend to collect from the patient. Likewise, don’t issue a receipt that says the patient paid the co-payment when they didn’t.
• Invoice for a service that you didn’t directly provide without indicating that the service wasn’t provided by you. For example, if someone under your supervision provided the service, such as a chiropractic student, kinesiologist or athletic therapist.
• Invoice for a treatment or service you provided to a patient under their dependent’s or family member’s name and benefit coverage.
• Have a patient sign a claim form in advance of receiving a service, product or device.

The previous examples are all Benefits fraud and could cause an insurance provider to decide to delist you and/or your clinic.

Spotlight on Co-Payments

You may wonder why you can’t waive a co-payment for a client who is having difficulty affording care. It’s important to understand that co-payments are an intentional part of the health care benefits plan design.

By adding a co-payment, the employer (Plan sponsor) is asking the patient (employee) to bear a portion of the cost of their care. Employers and insurers view this as a way of controlling costs and utilization rates. When a patient submits a claim for reimbursement, they must agree to the terms and conditions set out in their benefits contract, including co-payments.

The benefits contract exists between the employer and the insurance provider. Any change to these terms and conditions must be negotiated between the patient, their employer and/or their insurer.