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REP 14 - On giving a deal: navigating discounts, forgiven co-pay and package rates

Melissa Anderson, PT

We all love to get a great deal on a service we need.  Providing specials, coupons or package deals is a great way to advertise and bring in new customers, right?  

In a regulated health profession, like physiotherapy, things might be a little trickier.

As you read this, please realize that each province has its own standards of practice and advertising regulations.  While this may provide some ‘food for thought’ you should check with your provincial college for guidance in your particular jurisdiction.

 

Discounts

As a general rule, physiotherapists are allowed to discount their listed prices as they see fit.  Sometimes, a patient is unable to pay the full price, so the clinic offers them a special price or provides the service on a pro bono basis.  

This is acceptable under most provincial standards of practice, as long as the receipt provided indicates the actual amount paid.  

If the receipt is for a higher amount than what the patient actually paid, the client may receive more of a reimbursement than their plan allows, which could put both the patient and the provider in an compromised situation and leave them open to allegations of insurance fraud.

 

Packages

Some clinics like to offer package deals to their clients.  You will need to check with your specific provincial regulator for the acceptability of this in your province- but in most cases you cannot do this.  

Essentially, you are selling a service which the patient may not need.  The patient may buy the package of 10 treatments, but actually be feeling better after only five visits.  If they have a package, they may come for additional, unnecessary treatments just so they don’t lose money.  

If they choose not to come, they have paid for a service which they did not receive.  

Ontario recently changed their regulations around this, and do allow package deals, as long as there is a method for receiving a refund if all of the package is not required.  Again, to be sure- check with your college.

 

Forgiven Co-Pay

Sometimes clinics will offer to forgive the patient’s co-pay fee or use some creative bookkeeping to charge the insurance company more so their patient has to pay less out of pocket.  

While at first glance, this may seem like you are being kind to your patient, this is actually a form of insurance fraud and could get both you and your patient into trouble. 

Some providers have lost their license or their ability to direct bill insurance companies, and some clients have lost their insurance – and in some cases, their jobs – over issues like this.

 

Billing for Other Services

What happens when your client runs out of physiotherapy coverage, but still needs physiotherapy services?  

We may know that they have coverage for other services that they have not used.  

Surely, no harm can come from billing them for another service, like massage therapy or acupuncture, but still providing physiotherapy, right…? 

Wrong!

Again, this practice can be viewed as insurance fraud.  A physiotherapist can only bill for physiotherapy sessions.  

Acupuncture may be part of the treatment we provide in a physiotherapy session, but it must be invoiced as a physiotherapy session.  And an insurance company may ask to see your clinical documentation- so you must document what exactly was done during your physiotherapy session.  

Contrary to some perception, insurance fraud is not a victimless crime – everyone who pays into a group benefits plan (employers and employees) will need to pay more to offset the high cost of fraud.

 

Most physiotherapists have entered this profession to help people.  

In providing package deals and forgiving co-payment fees, physiotherapists may actually be harming their clients and putting their professional livelihood on the line.  

If you are considering offering a special deal or advertising a package, it would likely be in your best interest to think about your plan from multiple perspectives: 

  • How does this look if I am a potential client?  
  • An existing client?  
  • A third-party-payer?  

It might be well worth your time to call your provincial regulator and ask their opinion on your plans.  It might save a lot of trouble later!

 

Over to you

Can you see how making these kinds of offers can cause unintended harm?

After reading this, will you make any changes to your current business practices?

 

By Melissa Anderson, P.T., Senior Policy Advisor, CPA

 

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Comments

You are incorrect on one part here...physiotherapists CAN bill as acupuncturists, Kinesioloigsts, etc if they have registration with those appropriate colleges.  They must, however, document separately and keep records according to the standards of practice of the respective college.  They must also ensure that the client understands which scope of practice they are practicing under.  But a physiotherapist that is also a Kinesiologist or an Acupuncturist registered with those respective Colleges is able to bill using those registrations.

As far as waiving a co-pay is that a problem?  Pharmacists do it daily, so there is nothing in the RHPA in Ontario preventing that.  And under the CPTO, I see no standards of practice suggesting this to be an issue.  Where are you referencing this from?

The issue of co-pay is not an RHPA but the insurance company's policy that they have with the beneficiary of the plan (our patient). The plans are set up that the claimant is provided a health benefit as laid out upon agreement that they pay a portion of the the service i.e. a percentage of the fee. Our part as the provider is to provide accurate and transparent invoices/receipts for services rendered. If our fee is say $50.00 and the plan is 80% paid by insurer and 20% by the benficiary of the plan, then we are obliged to collect the 20%. If we do not then we are conspiring with the beneficiary to commit fraud; we have broken the agreement (together with the patient) of the insurance policy. 

However, we, as the physiotherapist can reduce our fees all we want and lets say we reduced it to $40.00 (which happens to be a 20% reduction off our original fee in this example-- we can do that!) BUT the invoice has to say the service cost $40.00 and then the person now pays $8 dollars and the insurer will pay $32 (still a 80/20 split as per the insurance policy and agreement that the individual has with the company AND we are not then co-conspiring!).

There are plans that are flat rates as well and are easier for all to understand; such as plan pays $25.00 per visit. In these cases, the patient pays the difference (or you could waive it down to $25.00 and the insurer pays it all but you receive only $25.00) No infringement of the policy has occurred. BUT, I have had patients who try to ask me to split my $50.00 service into two visit dates of $25.00 (and that now, is conspiring to commit fraud and is not accurate of the service provided).

This billing and collecting of fees really should be easy, as it is "black and white" (written down as blank ink on white pages of their policy)!

Just quick note, if you are treating in the capacity of the acupuncturist (as opposed to within scope of physiotherapist) this is something the client is clearly aware of -- question is how do you document that so that role delination is clear and transparent to a third party if your records were audited?

 

Thanks for thoughtful post.  Always lots to think about.   I am a PT over 25 years private and public sector - now returning to private sector as a sole proprietor.  Finding the marketplace is highly proliferative and as a PT I have to put on my critical thinking hat the same way I do with appraising literature!

Wow its lots of brainwork!

 Quick question if anyone has any thoughts.

Scenario: What if we as PTs are the "customers" and are being offered discounts and  freebies  -- to review educational products marketed by "other PTs" --for clients I may identify as potential consumers in my practice (e.g. educational products, online courses, workshops about conditions or self-managment programs).

Q1: Its one thing to send out a blitz and say "hey fellow PTs" here are some resources you can let your clients know about -- but when the originators start offering free e-books (that perhaps I previously purchased independently as a PT)..is this crossing a line?

Q2: Also what if it is an online course and is marketed as the first 5 sessions are always free -- and if you want more learning you need to pay.  On the one hand I understand the information is made accessible -- but in public sector there aren't financial limits to educational material yet in private sector involves fees are involved for just about everything.  Ethically I am having a hard time negotiating for myself, while full well knowing we all need to make a living.

Q3: Also what if the originators are individuals who are credentialled and visible and that information is used as part of the marketing.  Not to say the individuals aren't credibe -- but where is the line?  I can't see it so I don't know if its being crossed.

Thank you very much!

 

Thank you for your tough questions. I would refer you back to the CPA's Code of Ethics and the standards of practice from your regulatory body (especially the one re conflict of interest.) When in doubt, call the practice advisor at your regulatory body.

@CPA_Chantal

Seems very black and white.  However, we are often asked to provide receipts that say acupuncture instead of physio once physio benefits have run out. I always ask them to check with their insurer to see if they accept acupuncture provided by a physiotherapist.  The receipt still says who provided the service and my MSP billing number. It seems to me as long as it is clear who is providing the service there is no basis to say that fraud has been commited by either party. 

 

 

 

 

Billing an insurer for an accupuncture treatment when you actually provided a physiotherapy treatment is fraudulent.

Ethically, do you think it's right to change the title of the service to acupuncture instead of physiotherapy? Legally, you could be right, but as physiotherapists, we do obide by an ethical code of conduct that demands for transparency, as well as removing any conflicts of interests with earning increased revenue.

You MUST be registered to provide the service of acupuncture OUTSIDE of you PT registration.  In other words, if you retired from being a PT and gave up your license, would you still be authorized via another profession/governing body to provide that controlled act?

If you are exclusively registered as a PT, then you cannot bill for acupuncture.

If the service provider (for physio) doesn't increase there fee and bills insurance say $100 (the standard fee), for which they get $80 (coverage is 80%) and then they never collect the $20 (the waive it) if this fraud? They do give reduced rates for people without insurance. I think it would be fraud, and they should just give the $20 discount off the top then bill insurance, and I pay the remaining, but they wont do this and insist they are doing nothing wrong! Im so confused and just trying to do the right thing

Yes, it is still fraud. By not collecting 20%, the insurance policy has been negated and broken, therefore = fraud. If they indicated a $20 discount off the top, the insurance company will see that and payout 80% of the discounted price (100-20=$80) and thus your provider will only be able to collect $64 instead of their expected $80. There is no way around avoiding this co-payment issue. You are going to a provider who is commiting Insurance Fraud.

They way you describe this situation, it certainly sounds like fraud. Any discount should be noted on the receipt, and the receipt needs to be transparent and identify what was actually paid.  Then the insurer can reimburse as per the plan details.

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