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FoundationalFeeScheduleFundamentalsIt is important tohaveabasicunderstandingof thedifferentcomponentsof thecollectionprocess.Oneof themostcommon is the doctor’s fee schedule. Unfortunately, this is not simply a dollar amount listed on a piece of paper.Althoughclinicsmayhavesetfeeschedules,therearemanyothermovingpartstoconsider.Thisdocumentprovidesabriefoverviewofsomeofthefoundationalpiecesofthissystem.Attemptingtoaddressanyoneofthesecompliancecomponentswithoutconsideringthewholesystemputsapracticeatriskandcannegativelyaffectthebottomline.ActualFeesThe“actual”feescheduleforapracticeisalsoknownastheChargeMaster.Thisisthepre-defined,masterpricesetforeachserviceandcodeofferedintheoffice.Often,it’srecognizedasthefeethatisbilledforallserviceswhensendingchargestoathird-partypayer.Therearemanywayshealthcareproviderscandetermineactualfeesforserviceswhenopeninganewpractice.Thesecanrangefromsimplyguessing,throwingadartataboard,callingotherprofessionalsinthecommunitytoseewhattheyarecharging,and/orusingMedicare’sRelativeValueUnits(RVUs).The Sherman Anti-Trust Act prohibits price-fixing or collusion when setting fees. Setting actual fees is a thoughtful,research-basedprocessthatincludesexploringmanyfactors(e.g.,thecommunity,aNationalFeeAnalyzerscheduleforyour region, participation in various third-party contracts and their fee schedule limitations, and the practicedemographics).

GoverningPoliciesforYourFeeSystem

RegulatedFees

Hardship/IndigenceDiscount

ActualFees

DiscountedFeesforUninsured,Under-Insured,orPartiallyInsuredIndividuals

DiscretionaryDiscounts

FeeScheduleFundamentals

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DiscountedFeesforUninsured,Under-Insured,orPartiallyInsuredIndividualsAnnual surveys regarding reimbursement in the profession often reveal layers of discounts typically offered to cash-paying patients, those with poor insurance coverage, and a few other situations. An uninformed provider mayunintentionally commit violations of state/federal laws or provider agreementswhen charging one fee to an insuredpatientandanotherfeetoacashpatient.Undertheguiseofa“time-of-servicediscount,”manypracticesclaimtohaveadiscountifyou“paynow,”versushavingtheofficesubmittoaninsurancecarrier.This“deal”isusuallyonlyofferedtothosewithout insurance!Evenifthisdiscount isofferedtoallpatients, it is impractical.Averysmallhandfulofstateshaveclarifiedwhat“time-of-servicediscounts”actuallymean,andwhatdiscountpercentageisconsideredreasonable.Becausemost states have not set these standards, providersmust rely on federal guidance provided by hospitals toclarify theparameters.Theamountof thediscountofferedat the timeof service isusuallybasedon the savings theoffice will realize by NOT having to submit a bill to a third-party payer. According to federal guidance, 5-15% isreasonableforatime-of-servicediscount,buttheDCmustquantifyhows/hearrivedatthelevelofdiscountofferedinthe compliance policy. There are other rules and regulations for discounts when it comes to billing commercialinsurances or Medicare. Because Medicare patients have partial insurance (i.e., coverage for medically necessaryadjustments, but nothing else) they are cash-paying patients for statutorily excluded services. Tread carefully whenofferingdiscountshere—therulesareclear!KMCUniversity strongly recommends that providers consider offering cash-baseddiscounts beyond5-15% through anetwork-baseddiscountprogramlikeChiroHealthUSA.Usingthesamebasiclogicandcomplianceasusedfordiscountedfees intheircontractualrelationshipswiththird-partypayers,ChiroHealthUSAhasdevelopedaNetworkthatworks inconjunctionwith aDiscountMedical PlanOrganization (DMPO) to provide safe, legal discounts that actuallymake iteasiertoseethesetypesofpatients.DiscretionaryDiscountsAlthoughourprofessionisoneofthemosthighlyregulatedprofessionsinhealthcare,providershavetherighttoofferdiscretionarydiscountsoraccommodations-at-will.Thechallengeformostpractices isthelackofwrittenpolicyabouthowandtowhomthesediscountscanbeoffered.Agreatexampleof this is thepracticeofofferingfreechiropracticcaretoofficestaffmembers(andinsomecasestostaffmembers’immediatefamilies).Fellowchiropractors,theirfamilymembers,clergy,thedoctor’sfamily,themilitary,andfamilyfriendsmayalsobeofferedfreeordiscountedcareintheoffice,buttherearerulesthatmustbeconsideredbeforerandomlyofferingthesediscounts.Whileaprovidermaybeabletoofferdiscountsathis/herdiscretion,iftherearenorulesinwritingregardingdiscountss/hemayinadvertentlycause unintended violations (e.g., Offering a discretionary discount policy to treat office staff at no charge).When ateammemberisinvolvedinacaraccident,andhasautomed-payavailabletopaythebill,doesthestaffmember’sfreecaregooutthewindow?Whatifthedoctor’sfamilymemberhasinsurance?Doestheofficebillthecarrier,butwaivethedeductibleandcopayments?Thesearethekindsofsituationsthatcauseproblemswhennotclarifiedintheofficepolicy.Ifyourofficeoffersthesediscretionarydiscounts,thepolicyshouldbeveryspecificforeachpotentialsituationinordertoavoidmajorissuesrelatedtoillegaldiscounts.Hardship/IndigenceDiscountTheGovernmenthasacknowledgedthefactthatfinancialhardship isveryreal,andthatmedicalbillsarethenumberone cause of bankruptcies in theUnited States. In 2013,more than 2million bankruptcieswere filed due to unpaidmedicalbills.Patientsoftenneedassistancewithmedicalbillsforavarietyofreasons.Anofficehaseveryrighttoofferahardshiporindigencepolicy.YourDCcanmakeandcustomizeafeescheduleaccordingtothedictatesofthepractice

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demographics.Themistakemostprovidersmake is simply stating, “Yes, that constitutesahardship, so I’ll giveyoua(thens/heinsertsthenumberthatpopsintohis/herheadthatday)discount.”Withoutawrittenpolicythatdetailsahardshipandhow it is verified, this is adiscount innameonlyand isprobably randomandnon-compliant.Thegoodnewsisthatit’seasyforaprovidertosetandfollowahardshippolicyinyouroffice.Oncethepolicyisimplemented,theDCshouldsettherulesforwhowillbeconsideredforhardshipdiscounts,andcommunicatehowthathardshipistobeverified. If any of these steps are left out, the office is in danger of a non-compliance violation due to fee scheduleinconsistencies.Itissimpletoinitiateahardshippolicy,butonceitissetandtheproceduresarecreatedtoimplementit,itisyourresponsibilitytofollowittotheletter.Documentationisyoursafetynet.RegulatedFeesTherearecertainfeesinthepracticefeesystemregulatedbyoutsideentities.TherearefeessetannuallybyMedicarefor the three spinal Chiropractic Manipulative Treatment codes, and there may be regulated fees in your state forWorker’sCompensationorPersonal InjurySystems.These regulated feesare required forpatients that fall into thesecategories.Accordingtotheregulations,theofficemustacceptthatfeeschedule(thusthename“regulatedfee”).Whilethisisimportanttothefeesystem,practicesoftenfailtolookatregulatedfeesinthesamecontextasotherfeesintheoffice(e.g.,ifyourstate’sWorker’sCompensationregulatedfeescheduleisHIGHERthanotherfeesinyoursystem(suchas theActual Fee) your existing fee structuremaybeout of balance). It is important to studyall of the fees in yoursystem,includingregulatedfees,especiallywhenchangesaremadetoanyoneofthefeetypesmentionedinthisfactsheet.Regulatedfeesareoftencontrolledbygovernmentalagenciesandrequireyoutoadheretothemwhenworkingwith patients in that category. For maximum reimbursement, this set of fees shouldn’t be discounted. If you havequestionsaboutthefeescheduleinyouroffice,takethemtoyoursupervisororDC.GoverningPoliciesforYourFeeSystemOncetheDChasreviewedtheentirefeesystem,s/hesetstheactualfeesbasedontherealitiesofthepractice.OncetheDChasinstalledsimple,legaldiscountedfees,andquantifiedthehardshippolicy,s/hemakesitofficialbycreatingawrittenpolicy.TheDCoryoursupervisorshouldprovideclearexpectationsabouthowthepolicyistobeappliedinyourpractice. As with all types of compliance policies there are 3 critical steps the practice should follow to ensurecompliance: 1) set the policies; 2) write the policies down; 3) train all staff members on how to apply the policies.Writingapolicyforeachtypeoffee;outlininghowitistobemanagedinthepractice;andprovidingguidelinesforhowit’sadministeredsetthestageforsuccess.Oncethepoliciesaredetermined,theDCwritestheprocedureforeachfeeclassificationoutliningtheexactstepsnecessarytoensurethepolicyisfollowed(e.g.,forahardshippolicys/hedefinesthe typesofhardship thatare recognizedandhoweach type isverified).Thesewrittenpoliciesandwrittenstandardoperating procedures are the guiding principles for you to follow. With them, any outside entity reviewing officecompliance for any reason can easily see that you are striving to be compliant; and fee schedule compliance is animportantprincipleinyourclinic.