This brief presentation describes the basics of third party billing for Surgical Assistants.

1. BILLING OVERVIEW FOR THE
SURGICAL ASSISTANT
Luis F. Aragon, RSA
Surgbill Inc.

2. Managed Care Models
Exclusive provider organizations (EPO)
Integrated Delivery System (IDS)
Health maintenance organizations (HMO)
 Direct Contract model
 Group Model
 Individual Practice Association
 Network model
 Staff model
Point of service plan (POS)
Preferred Provider organization (PPO)
Triple option plan
Luis F. Aragon, RSA
Surgbill Inc.

3. CONSUMER DIRECTED HEALTH PLANS (CDHP)
They are becoming a popular alternative to the increased
costs of traditional health insurance premiums and the
limitations associated with managed care plans.
 Tax exempt accounts
 High deductible insurance policy
 Disadvantage is the gap between the expenditure of
the account and the deductible.
 We as SAs need to monitor this one closely as we do
not know how is it going to play out in the future.
Luis F. Aragon, RSA
Surgbill Inc.

4. Clean claim
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Surgbill Inc.

5. Life Cycle of an Insurance Claim
Luis F. Aragon, RSA
Surgbill Inc.

6. Terms to know
Coordination of Benefits (COB)
Non-covered benefits vs unauthorized services
Allowed charges for the CPT in question
Deductible
Co-insurance
Co-payment
ERA vs EOB
Luis F. Aragon, RSA
Surgbill Inc.

7. Facts to know
Patients can be billed for non-covered procedures, but not
for unauthorized services. Providers process denials of
unauthorized services as a business loss.
Claims are adjudicated by line item (not for total charges),
which means that payers bundle and edit code numbers for
individual procedures and services. Each payor may be
different in their code edits. Payors are known for not
applying official coding guidelines for ICD-9 and CPT codes.
The patient is responsible for co-payments and deductibles,
but does not pay more than the allowed negotiated rate.
Luis F. Aragon, RSA
Surgbill Inc.

8. No Out of Network benefits
Luis F. Aragon, RSA
Surgbill Inc.

9. Co-insurance
Luis F. Aragon, RSA
Surgbill Inc.

10. No balance billing allowed
Luis F. Aragon, RSA
Surgbill Inc.

11. Deductible
Luis F. Aragon, RSA
Surgbill Inc.

12. Co-insurance
Luis F. Aragon, RSA
Surgbill Inc.

13. To bill or not to bill! (Patients)
This is an issue of debate nationwide in the Surgical Assistant
industry.
Facilities and surgeons want the advantage of our services for free
or for a minimal fee but do not want their patients to be bothered
with an additional bill.
We recommend billing for deductibles and co-payments, but
strongly advise against balance billing or when the plan does not
have out of network benefits.
And even deductibles and co-payments fall in the out of network
category, you have to make sure that your surgeons and facilities
know that you are engaging in this practice.
Facilities and surgeons prefer for us to be on the background much
like the CRNAs, and this has worked as a win-win situation for
both parties, but what is going to happen when CDHP plans start
to take off?
Luis F. Aragon, RSA
Surgbill Inc.

14. Bottom Line
Your practice has to be prepared for the following issues:
√ Billing patients and for what portions are you going to be billing
√ Employer sponsored plans (e.gr., labor unions administered by
BC/BS) make the determination to reimburse or not to reimburse
from within and are regulated federally (ERISA) not by the State.
√ All HMOs are federally regulated, therefore if they decide they do
not want to reimburse, they don’t have to.
√ Most commercial, PPOs, EPOs, BC/BS will reimburse for your
services.
√ Please be vigilent on some entities called ACOs, this is a direct
result of Obamacare and it will start rolling out in January 2012.
Luis F. Aragon, RSA
Surgbill Inc.

15. AMA Council on Ethics and
Judicial Affairs
Opinion Issued: The AMA has
acknowledged that routine waivers
of coinsurance/deductibles
constitutes fraud, and proclaims the
practice to be unethical.
•http://www.ama-assn.org/ama/pub/category/4615.html
Luis F. Aragon, RSA
Surgbill Inc.

16. AMA Council on Ethics and
Judicial Affairs
• Opinion 6.12 - Forgiveness or Waiver
of Insurance Copayments:
Physicians should be aware that
forgiveness or waiver of co-payments
may violate the policies of some
insurers, both public and private…..
Routine forgiveness or waiver of co-
payments may constitute fraud
under state and federal law.
Luis F. Aragon, RSA
Surgbill Inc.

17. HIPAA Section 242
(Public Law 104-191 104th Congress) Title II, Subtitle E
Whoever knowingly and willfully executes, or
attempts to execute, a scheme or artifice-- (1) to
defraud any health care benefit program; or (2) to
obtain, by means of false or fraudulent pretenses,
representations, or promises, any of the money or
property owned by, or under the custody or
control of, any health care benefit program, in
connection with the delivery of or payment for
health care benefits, items, or services, shall be
fined under this title or imprisoned not more than
10 years, or both.
Luis F. Aragon, RSA
Surgbill Inc.

18. Fraudulent & False Statements
 Professional courtesy discounts in the
form of a waiver of a co-payment or
deductible constitutes both health care
fraud and false statements.
 Knowing you are required to collect a co-
pay or deductible but billing insurance only
is committing health care fraud;
 By billing an insurance company one
charge but failing to collect the patient co-
pay or deductible, the provider is making a
false statement regarding the charge.
Luis F. Aragon, RSA
Surgbill Inc.

19. What Does OIG Say?
In 1991 the Office of Inspector General
(OIG) issued a fraud alert concerning the
wavier of co-pays and deductibles. The
OIG stated that billing “insurance only”
may violate the False Claims Act, the Anti-
Kickback Statute, the Civil Monetary
Penalties Law, 42 U.S.C sec 1320a-7a(a)
(5), as amended by Pub.L.No 104-91 sec
231 (h), and State laws.
Luis F. Aragon, RSA
Surgbill Inc.

20. What Does OIG Say?
• Routine Waiver of Deductibles &
Coinsurance Prohibited
• 1994 Special Fraud Alert -
http://oig.hhs.gov/fraud/docs/alertsandbulletins/121994.html
• 1991 Safe Harbor Regulations Alert –
• http://oig.hhs.gov/fraud/docs/safeharborregulations/072991.htm
Luis F. Aragon, RSA
Surgbill Inc.

21. What Does OIG Say?
• Waivers of Cost-Sharing Amounts For
Financially needy Medicare & Medicaid Patients
Permitted:
3) Waiver must not be routine;
4) Waivers may not be offered through
advertisement or solicitation;
5) Waivers may only be offered after determining
in good faith that there is a financial need or
when reasonable collection efforts have failed
•See testimony, Lewis Morris, Chief Counsel to OIG, 2004
http://oig.hhs.gov/testimony/docs/2004/40624oig.pdf
Luis F. Aragon, RSA
Surgbill Inc.

22. What do I do then?
PROVIDE AN ABN (Advanced Beneficiary Notice) during the first
visit to your surgeon’s office:
Your doctors utilize a Surgical Assistant during some surgeries
that the hospital or your surgeon deem necessary, this assistant is
not provided by the hospital. The fee for the assistant is 20% of
the surgical charge, he/she will bill your insurance carrier,
however if your insurance does not cover this service it will be
your responsibility. In addition most insurance plans do not
contract with Surgical Assistants and therefore this charge might
be an out of network expense, please confirm with your insurance
carrier for verification.
CYA
Luis F. Aragon, RSA
Surgbill Inc.

23. Questions?
Luis F. Aragon, RSA
Surgbill Inc.