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    Help uninsured patients without hurting your practice


    Setting rates & understanding restrictions

    Practices should have a self-pay fee schedule in place in the event that patients without insurance want to stay with their doctor, Morgan says.

    While resources such as the Healthcare Bluebook—a guide that suggests prices for healthcare services based on billing and medical payment data—can provide one framework for setting rates, practices could also look at their payer fee schedules and come up with a starting point, she says, or begin with the Medicare fee schedule.

    However, practices should be mindful of potential regulatory and contractual restrictions. “Whenever there is going to be a decision to reduce the charges or provide free care, it has to be in the benefit of the patient, not the provider,” Cullen says. “In other words, it can’t be a loss leader, which would be considered fraud.”

    Some states may have laws or restrictions that prevent doctors from charging less than Medicare rates, Morgan notes.

    “Also, practices should review their contracts to be sure that there is no language that makes giving discounts to other patients—even uninsured or differently insured patients—a violation,” Morgan says.


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    Such terms are often referred to as “most favored nation clauses,” she says. “They’re less common now, but if you have a contract that’s been in place for a long time and you haven’t revised it, you could have that stipulation.”

    Moreover, it’s critical for practices to check with payers to understand whether and how financial hardship must be demonstrated, and what types of discounts are permitted, she says. Limits on the amount of discount care that can be provided may also be built into those contracts, she adds.

    Local health programs, such as city-provided insurance or Medicaid, may also have restrictions, she says, so practices should be sure they understand any and all legal limits to the discounts they contemplate offering.

    Hardship policies in practice

    In Amherst, Mass., Katherine J. Atkinson, MD, owner of Atkinson Family Practice, says she’s able to offer a liberal discount policy because the number of patients who need it is relatively low.

    The practice’s established hardship policy sets an alternative fee schedule based on rates published in the Healthcare Bluebook. For patients willing to prepay the entire amount at the time of their visit rather than in installments, that self-pay fee schedule is discounted by an additional 60 percent.

    At Coastal Medical Inc., in Cranston, Rhode Island, self-pay rates are set by the corporate office, but physicians determine how many uninsured patients they’re willing to see, says Ejnes.

    “Even though we’re a large group and our physicians are technically employed, a lot are shareholders, which gives us a lot of autonomy,” he says. “Physicians who don’t mind making less margin to see more uninsured patients can certainly do that.”

    Ejnes does not have specific numbers of uninsured patients he’s willing to see, and doubts his colleagues do either. “So there are no limits, per se,” he says. “Our physicians, whether shareholders or employees, can write off care for a patient if they believe that is the appropriate thing to do.”

    The employed physicians in the group are paid using a formula that gives them the latitude to provide reduced-cost or free care if they choose, he adds.

    Practices should consider asking pharmaceutical companies and medical device manufacturers about any financial assistance programs they offer to patients, Morgan says. She also recommends keeping a list of health insurance and community resources at the front desk.

    In addition to the resources listed in the accompanying sidebar, many senior centers can help patients sign up for Medicare and other programs, Ejnes says. 

    Physicians might also consider partnering with local free clinics or hospitals. For example, Coastal Medical physicians see some patients who are eligible for the Rhode Island Free Clinic, which faces capacity issues, in its own office. This arrangement keeps both the free clinic and other local medical offices from having to turn patients away.

    And Valdez Medical Clinic has an agreement with Providence Alaska Medical Center whereby if the hospital has provided charity care to a patient, that the group will honor that discount as well. 

    “We didn’t have the resources in our clinic to do assessment of individuals’ financial status,” Cullen says, “so we decided to partner with the hospital.” 


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