The story goes that the Lone Ranger wore a mask because he was one of a group of Texas Rangers that got ambushed. All were killed, save one lone surviving Ranger. The lone Ranger was injured and probably would have died, except an Indian by the name of Tonto, came along and saved him. After the Ranger recovered, Tonto made him a mask to wear until they caught the gang that ambushed him. Once the last outlaw was in jail, the ranger decided to keep the mask and his new name until the West was free of crime. And so the legend began…
I relate this story because I think of our FairCareMDs, PhDs, DOs, DDSs, DPMs, DCs, RNs,… as the Lone Rangers of Medicine and our system as the mask that let’s them do good deeds. A little dramatic perhaps, but let me explain.
When you search for prices from doctors on FairCareMD they are often masked. Either they are without a price or they are higher than you would expect. So who is the bad guy in black preventing this? Well, you can’t really point to one, it is more of a systematic problem. Before the internet, the idea of doing mass negotiating with everyone quickly and easily was impossible. As a result many standard practices and regulations were enacted that make publication of a fair price a risky business decision for medical doctors. As a group, doctors, just like the Texas Rangers, a are pretty conservative bunch – which is a good thing!
In fact, most medical doctors check with their lawyers before signing up for FairCareMD and we don’t blame them. Our expert healthcare attorney did a good deal of research to help us create this system and we can now cite the regulations and the advice of the Office of the Inspector General that allows this (see below) but at the end of the day, every doctor must decide for her or himself if offering a Fair Price, even when masked, to the public, is worth the risk of dealing with complex regulations. Just like the Lone Ranger, each doctor must decide to put on his mask for the greater good. The good news is that FairCareMD’s masking of the doctor’s fair prices protects well. This conclusion is based upon thousands of precedents and how the regulations work. As long as the “Usual fee” is above a certain rate, he or she will not be penalized. It is an elegantly simple solution that works well for everyone, just like that little black mask.
Here is how it works:
First the doctor enters three prices for a specific set of services that may or may not correlate to the standard fee schedules (this is important as it avoids apples to apples comparisons.) Incidentally, we also don’t believe that most of the 67,000+ codes used to bill medical services add anything to actual care, so we let the doctor’s make up their own offerings.
These three prices are there to make deals go through IMMEDIATELY if the Requested price is considered fair!
List Price (the LP or “the mask”): The only published price – generally as low as a doctor can safely list without increasing risk but still surprisingly high in many cases.
Low Acceptable Price (the LAP): The price that needs to be masked or what the doctor considers a fair fee for the service.
Rejection in Price (the RIP): The low bar that even on their worst day, they would not accept.
The patient then requests a price, armed with the HealthcareBlueBook price. If it lands above the LAP, then they automatically get a DoneDeal, a contract for services at the requested price. If the requested price is below the RIP, they are out of the game. Anything else, they need to wait for a response from the doctor.
Here are the rules:
1. The Patient only gets ONE request per offer
2. We require the patient to register before they can make a second request on any offer.
3. If patient makes several DoneDeals and doesn't show up then this is displayed on their profiles and access to deals are restricted.
So let's take a Spinal MRI on FairCareMD as an example. Here we might find it listed for $1,250. The facility's regular rate for this is $1,900. We tell you that Healthcare BlueBook, our partner that gives the average insurance payment for procedures in any zip code in America, says $663 is a fair price. If the patient requests a Fair Price, or something above the LAP, $700, they will get an immediate response and a contract called a DoneDeal. If they go too low, say 450, the doctor may accept it but they have to wait for the doctor. If they go too low, $350 or so, they will get an automated rejection because this is below the RIP.
Maybe you are too young to remember the line at the end of the show - but I do. One person would often say, "Who was that Masked Man?" and the other would reply, "I don't know, but I'd sure like to thank him!" Well, this isn't a 50's western TV show, so here patients can thank their masked men and women directly through our new reviews system!
Patients also get their own mask too since health information is private information. All our privacy settings (unlike facebook's) are set to "keep private." You can unmask at will, but we protect you as well. Thank them not only for great care, but also for having the intestinal fortitude to try to change healthcare for the better. Without them, this system would be nothing but an empty mask. Give it a try, we think you will love it!
For those gluttons for punishment that would like to read our legal opinion on this matter, it is below. This is just a summary, but you get the idea. This is not legal advice, just a summary of our research. Medical and Dental Providers: Please consult with your own attorney before deciding to participate with FairCareMD.
On February 2, 2004, the Office of the Inspector General of the U.S. Department of Health and Human Services ("OIG") issued guidance to hospitals that wish either to provide discounts to uninsured patients or to reduce or waive Medicare cost-sharing amounts for patients experiencing financial hardship. The guidance does not provide any new interpretations of existing law or regulations, but may provide some reassurance to hospitals that they are not violating the law when providing these discounts.
The OIG advised that neither the federal anti-kickback statute (42 U.S.C. §1320a-7b(b)), nor the relevant provision of the OIG's permissive exclusion authority (42 U.S.C. §1320a-7(b)(6)(A)) restricts hospitals from providing financial relief to their uninsured patients. The OIG also outlined the two existing exceptions to the prohibition against routine waiver of Medicare cost-sharing amounts for hospital services.
1. Discounts for Uninsured Patients Who Cannot Afford to Pay Their Hospital Bills
A. Federal Anti-Kickback Statute
B. OIG Permissive Exclusion Authority
The OIG also reaffirmed its position, as set forth in proposed regulations issued last September (68 Fed. Reg. 53939) that it would not include "charges for services provided to uninsured patients free of charge or at a substantially reduced rate" when determining a hospital's usual charges under the statute. The OIG emphasized that it has never excluded or attempted to exclude a provider for offering discounts to uninsured or underinsured self-pay patients, and would continue its practice of allowing these discounts to these patients until it has considered public comments to its proposed regulations and has issued final regulations or has made public its intention not to promulgate final regulations.
2. Reductions or Waivers of Cost-Sharing Amounts for Medicare Beneficiaries
Although the routine waiver of Medicare coinsurance and deductible amounts is generally prohibited and can violate the federal False Claims Act (31 U.S.C. §3729), or the federal anti-inducement statute, (42 U.S.C. §1320a-7a(a)(5)), the OIG explained that there are two existing exceptions to this general prohibition.
Providers may waive a Medicare coinsurance or deductible amount in consideration of a particular patient's financial hardship when:
42 U.S.C. §1320a-7a(ii)(6)(A). In determining financial hardship, the OIG advised that hospitals uniformly apply a reasonable set of objective criteria such as the local cost of living, a patient's income, assets and expenses, family size and the scope and extent of a patient's medical bills.
It is important to be aware, however, that even if these criteria are met, the routine waiver of coinsurance and deductibles may still violate the anti-kickback statute, if one purpose of the waiver is to generate business payable by a federal heathcare program. (See 63 Fed. Reg. 14393, 14395 (March 25, 1998)).
B. Inpatient Hospital Services
Hospitals may also waive Medicare coinsurance and deductibles for inpatient hospital services. This exception is set forth in the safe-harbor regulations that apply to the anti-kickback statute, the anti-inducement statute and the OIG exclusion authority. 42 C.F.R. 1001.952(k). Under this safe-harbor, a hospital may waive coinsurance and deductible amounts for inpatient services for which Medicare pays under the prospective payment system if:
- the hospital does not claim the waived amount as bad debt or otherwise shift the burden onto Medicare, a State heathcare program, or other payers or individuals;
- the hospital offers to reduce or waive the cost-sharing amount without regard to the reason for admission, the beneficiary's length of stay, or the diagnostic-related group for which the claim for Medicare reimbursement is filed;
- the waiver is not part of a price reduction agreement between the hospital and a third-party payer (other than a Medicare SELECT plan).
Hospitals that wish to provide discounts to uninsured, underinsured, or Medicare patients should review the guidance.
This is just a summary but it gives a good overview. Once again, our attorneys want us to clearly state that THIS IS NOT LEGAL ADVICE! Please seek your own counsel.
Tags: Affordable Care, change we can make happen today, fixing the healthcare system, Future of Health Care, Healthcare Marketplace, innovation in healthcare, more self-pays, Transparency in Medical Pricing