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automatically invoke attorney–client privilege for communications to the plan’s
attorney.
d) Waiving Deductibles and Copays as Fraud
[This section adapted from Richards EP, Rathbun KC. Professional Courtesy. Mo.
Med. January 1998;95:18–20.]
Professional courtesy—taking care of the families of other physicians without
charge—is a tradition that dates back to Hippocrates. The practice served to build
bonds between physicians, and to reduce the incentive for physicians to treat their
own families. Although the authors believe that, on balance, professional courtesy
is good for the medical profession, the Congress and private insurance companies
have greatly reduced the permissible scope for reducing charges for medical care.
Since the penalties for violating these restrictions include denial of the claim,
deselection from the plan, fines, and imprisonment, medical care practitioners must
review their practices to ensure that they are in compliance.
Private insurers and the federal government have basic restrictions on how you
charge patients for medical care. Neither creates an exception for professional
courtesy: in general, if you cannot reduce the cost of care for anyone else in your
practice, you cannot reduce it for other medical care practitioners. There are even
situations where it is permissible to reduce the cost of care for everyone except
physicians.
(1) Waiving Copays
The most common ways physicians reduce the cost of care for patients are
waiving the copay (“insurance only”) and giving the patient a discount on the
care. In most situations, both private insurers and the federal government ban
waiving the copay. (Medicare has some provisions allowing the copay to be
waived for documented indigency.) They do this because the copay is meant to
discourage casual trips to the physician. The theory is that making the patient
share the cost of treatment will make the patient a more sophisticated health care
consumer. The reality is that the copay limits access to care for many people. The
less care the patient seeks, the less money the health plan has to pay to physicians
and hospitals for that care. Both private insurers and Medicare require the
physician to make reasonable efforts to collect copays that are billed to the
patient.
(2) Discounts
A discount is a reduction in the normal charge based on a specific amount of
money or a percentage of the charge. Just as the hardware store can give you $5
off on all tools or a 10% discount on your total purchase, a physician may take $5
off or 10% off of the bill for an office visit or a surgery. However, there are
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