New York Community Health has a full service, in-house billing department for efficient claims processing for all services offered under the NYCH umbrella. We offer this service to expedite insurance carrier payments.
REMEMBER: This in no way relieves the patient for the responsibility of their bill. The patient is ultimately responsible for all non-covered portions of their bill: co-payment, co-insurance, deductible, balance for partial payments and non-covered items.
PLEASE DO NOT ASK US TO WAIVE COPAYS, CO-INSURANCES OR DEDUCTABLES, or any other financial member responsibilities, as outlined in your benefits plan since IT IS ILLEGAL TO DO SO PER STATE LAW.
(Please read article below for details)
ABOUT COPAY, DEDUCTIBLE & MEMBER RESPONSIBILITIES
In order to avoid imposing significant financial hardship on patients, some physicians offer to discount or waive those amounts that are the personal responsibility of the patient. This is to be distinguished from the situation where the physician makes a conscious decision to treat each patient as PRIVATE PAY where there is greater flexibility in structuring payment arrangements without creating legal liability. As a general rule, a provider should not generally waive co-payments or deductibles. In the context of Medicare and Medicaid patients, this is prohibited in the absence of demonstrating financial hardship of the patient. Waiver of co-payments and deductibles by an Out-of-Network provider may be viewed as a potential kickback, insurance fraud or grounds for disciplinary action against the physician who waives the co-payments, co-insurance or deductible. In fact, the provider's waiver of co-payments or deductibles may also affect the provider's rights to collect insurance from the payor based on State law related to acceptance of assignment.
Under the legislation creating the Health Insurance Portability and Accountability Act (HIPAA,) it is considered mail fraud, to have a scheme intended to DEFRAUD ANY HEALTH CARE BENEFIT PROGRAM which is a crime under federal law. It is generally accepted that the routine waiver of copayments required by insurance contracts is illegal and fraudulent. The American Medical Association (AMA), American Dental Association (ADA), and American Psychological Association (APA) have all held in ethical opinions or articles that the routine waiver of copayments or deductibles is unethical, illegal, or both. Likewise, the U.S. Department of Health and Human Services has issued fraud alerts, clarifying that the routine waiver of copayments and deductibles under Medicare and Medicaid constitutes fraud and may violate the federal anti-kickback statute. Even local medical associations have recognized that systematic waivers can result in federal and state legal penalties.
Just as the federal government has taken steps to protect against the persistent waiver of copayments and deductibles, a number of states have statutes that implicitly or explicitly prohibit the practice. In fact, five states have adopted the Insurance Fraud Prevention Model Act, which implicitly makes the routine waiver of copayment illegal. A total of 47 states and the District of Columbia have addressed this issue through the state Insurance Department's general counsel, who issued an opinion letter stating that if waiver of copayments is employed as a "COMMON BUSINESS PRACTICE, the health care provider may be found guilty of insurance fraud in violation of Article 4 of the N.Y. Ins. Law."
There is no dispute that physicians who participate in managed care plans must comply with the terms of the provider agreements. Waivers or discounts of copayments or deductibles by in-network providers should be made only on the basis of demonstrated patient financial hardship. Medicare prohibits the routine waiver of copayments and coinsurance to Medicare beneficiaries. Medicare views discounts and coinsurance waivers as inducement to patients to choose a particular provider, especially if the discounts are offered at or before the time of service.
HOW TO PROVE FINANCIAL HARDSHIP
1. Collect all your bills, including your mortgage, utilities, credit cards, cellular phone and other accounts. It is crucial that you have supplemental documents because this is the only way that you can prove a financial hardship.
2. Total your monthly revenue and spending. Itemize the costs of food, rent, utilities, gas, house supplies and other needs.
3. Eliminate all unnecessary expenses from your life by asking yourself whether you can truly survive without that service. For example, you may want to eliminate monthly cable bills or subscription to gym membership that you do not use. This reduces your cost and shows that you tried to decrease your living costs.
4. Prove Womens all documents you collected including you tax return, your itemized costs and a letter explaining your financial hardship to show that you have a financial hardship and would like to request a waiver on your financial responsibilities.
What follows is a brief look at our billing process.
INSURANCE BILLING PROCESS
Once a service has been rendered by NYCH, WHC or any other affiliated business associates under the NYCH umbrella, the claims for the services are submitted to the appropriate insurance companies electronically with 24 hours. Once an electronic claim has been submitted it typically takes up to 2 weeks for the insurance companies to process the claim and submit the payments. This however is not always the case. Some insurance companies may even take up to 3 months to process the claim. Also, note that there are still some insurance companies that do not accept electronic claims and for those companies we have to mail in paper claims which may prolong the processing.
PATIENT BILLING PROCESS
Once a payment is received by us we review the Explanation of Benefits from the insurance company for any patient responsibilities. If all copay, coinsurance and deductible amounts have been met by the patient then we close the claim. If there are any pending balances then we send an account balance statement to the patient. All patient payments are due within 30 days of receipt of the first statement. If patient payments are not received then we send a Final Notice to the patient. If we do not receive the payment even after the final notice and the patient has not contacted us then the claim is submitted to an out side collection agency. Please note that once a claim is submitted to a collection agency it will accrue additional penalties, finance charges and processing fees. In addition, all discounts that may have been given to the patient may be reversed before submission to the collection agency.
RECENT INSURANCE BILLING ISSUES
In the last couple of months we have noticed that some insurance companies RECOUP the payments made to us initially. This may be due to an in-house audit that the insurance companies do periodically which results in them discovering that a given patient's plan had terminated or they had paid incorrectly. These Recoupment amounts could date back to past several years. In such cases we have to refund the money back to the insurance company and bill the patient for the services.
When faced with such a situation the patient has two options:
1) Pay us the account balance due, or
2) Fight the case with the insurance company if the patient feels that they were wronged.
In either case the patient will have to pay us so that we can close the case at our end to avoid submission to the collection agency.
BOUNCED PERSONAL CHECKS
If a patient check is rejected by their bank due to insufficient funds then we will add a $25 processing penalty & bank fees to the amount due and send the patient a new statement including the penalty.
FEE FOR SERVICE PATIENT BILLING
For Fee-For-Service patients all amounts are due on the day the services are provided. For large account balances an installment plan can be arranged on a case-by-case basis to help the patients out with their payments. If however the installment plan agreements are not met then we reserve the right to demand the full payment in a lump sum or submit the claim to the collection agency for the patients that refuse to cooperate.
For Questions about your account balances or statements received please call our billing department at 516-216-4964.
We are open Monday to Friday 10am to 5pm. For after hours please leave a message and we'll call you on the next business day.