What the statutes mean

When a chiropractor signs a managed care agreement he or she is voluntarily giving up some of their rights. One of these is the right to collect for their services directly from the patient. Under a traditional group health plan a chiropractor submits claims on behalf of the patient to their insurer. If the insurer does not pay, the chiropractor has every right to collect the unpaid balance from the patient.

A managed care agreement is different because a chiropractor negotiates the financial terms of their relationship with the managed care company. The law, however, provides protection to patients regardless of the deal between the chiropractor and the managed care company. A chiropractor that signs a managed care agreement automatically gives up the right to charge or collect from the patient for any covered service. This is true even if the managed care company gives them oral or written permission to do so.

The chiropractor may only collect the following from a patient:

• Amounts due for the patient’s co-pays or deductibles. (Remember, it is a violation of both statute and rule to waive a patient’s co-pay or deductible.)

• Amounts due for services that are defined in the agreement as non-covered.

The law explicitly prohibits a chiropractor from doing any of the following:

• Billing or charging a patient for covered services except for co-pays or deductibles.

• Collecting a deposit from a patient.

• Seek remuneration or compensation from a patient (This most often occurs when a chiropractor has signed a capitated managed care agreement and wants the patient to pay for care that the chiropractor feels was uncompensated by the managed care company.)

• File or threaten to file a report with a credit agency

• File or threaten to file a lien or any other action against a patient.

With the rapidly changing health care market a chiropractor may sign a managed care agreement with a company that is or becomes financially unstable. The law was written with the understanding that this could occur. But in the event the managed care company is unable to pay the chiropractor for his or her services, the law has been written to make sure that the patient has no financial risk. The following are examples of what a chiropractor may not do, regardless of what is in the managed care contract or agreement. The managed care company does not have the authority to waive these sections of the law.

• Even if the chiropractor has an oral or written agreement with the managed care company, he or she may never hold a patient liable for costs of covered care.

• Even if the managed care company breaches or defaults on their agreement, a chiropractor may not charge the patient for the cost of their care.

• Some managed care organizations act as conduits for other insurers or managed care organizations. Regardless which party does not fulfill its financial obligations to the chiropractor, a chiropractor may not charge the patient for the cost of their care.

• Even if the managed care company does not have the money to pay for care or declares bankruptcy, a chiropractor may not charge the patient for the cost of care.

• Even if the managed care company never paid a single claim of the chiropractor, he or she could not collect from the patient for the care they rendered.

• Even if a managed care organization itself has not complied with any section of this law, a chiropractor may not collect from the patient for the care they rendered. It is the responsibility of the chiropractor to determine if the managed care company has the financial stability to pay its claims. The law does not allow the patient under any circumstances to be billed for covered services.

Practical advice

¨ The financial stability of a managed care company is one of the risks a chiropractor accepts when he or she signs an agreement. This particular risk is one that many chiropractors do not consider because they incorrectly assume that any company in the managed care industry must have the financial resources to pay outstanding claims. As the list of bankrupt managed care organizations continues to grow, prudent chiropractors ask about the financial stability of the managed care organization before they sign the managed care agreement. A good accountant or attorney will be able to help you understand the relative financial strength of a particular company.

¨ Even though a chiropractor is not permitted to charge a patient for care, the chiropractor may be required to continue to provide services to the patient even if the managed care company goes out of business. A clause in the managed care agreement describes the length of time and the circumstances under which a chiropractor is required to provide care to the patient.

¨ If a chiropractor discovers that their managed care organization is undergoing financial problems, he or she may have a restriction in their agreement from discussing this fact with their patients. Even if the managed care company is failing to meet its financial obligations, the provider may still be restricted by the confidentiality provisions of the managed care agreement.

¨ The law states that chiropractors are prohibited from collecting from a patient for any covered service. Some managed care agreements specifically state that maintenance, preventative, or wellness care is not a covered service. If the agreement draws this distinction, a chiropractor is allowed to charge the patient for this care. To retain a positive working relationship with the patient, it would be important to let the patient know when the patient has entered the maintenance, preventative or wellness phase of care.

¨ A chiropractor may not charge the patient unless the managed care agreement specifically allows them to do so, If the agreement is silent on this subject, a chiropractors would have to negotiate a change in the agreement’s terminology if they wanted the option to charge for this care.

Statute excerpts

Restrictions on recovering health care costs.

609.91(1) Immunity of enrollees and policyholders. Except as provided in sub. (1m), an enrollee or policyholder of a health maintenance organization insurer is not liable for health care costs that are incurred on or after January 1, 1990, and that are covered under a policy or certificate issued by the health maintenance organization insurer, if any of the following applies:

609.91(1)(a) The health care is provided by a provider who satisfies any of the following:

609.91(1)(a)1. Is an affiliate of the health maintenance organization insurer.

609.91(1)(a)2. Owns at least 5% of the voting securities of the health maintenance organization insurer.

609.91(1)(a)3. Is entitled, alone or with one or more affiliates, to solely select one or more board members of the health maintenance organization insurer, or has an affiliate that is entitled to solely select one or more board members of the health maintenance organization insurer.

609.91(1)(a)4. Is entitled to have one or more board members of the health maintenance organization insurer serve exclusively as a representative of the provider, one or more of the provider’s affiliates or the provider and its affiliates, except this subdivision does not apply to an individual practice association or an affiliate of an individual practice association.

609.91(1)(a)5. Is an individual practice association that is represented, or its affiliate is represented, on the board of the health maintenance organization insurer, and at least 3 of the board members of the health maintenance organization represent one or more individual practice associations.

09.91(1)(am) The health care is provided by a provider under a contract with, or through membership in, a person who satisfies par. (a) 1., 2., 3., 4. or 5.

609.91(1)(b) The health care is provided by a provider who is not subject to par. (a) or (am) and who does not elect to be exempt from this paragraph under s. 609.92, and the health care satisfies any of the following:

609.91(1)(b)1. Is provided by a hospital or an individual practice association.

609.91(1)(b)2. Is physician services provided under a contract with the health maintenance organization insurer or by a participating provider of the health maintenance organization insurer.

609.91(1)(b)3. Is services, equipment, supplies or drugs that are ancillary or incidental to services described in subd. 2. and are provided by the contracting provider or participating provider.

609.91(1)(c) The health care is provided by a provider who is not subject to par. (a), (am) or (b) with regard to that health care and who elects under s. 609.925 to be subject to this paragraph.

609.91(1)(d) The liability is for the portion of health care costs that exceeds the amount that the health maintenance organization insurer has agreed, in a contract with the provider of the health care, to pay the provider for that health care.

609.91(1m) Immunity of medical assistance recipients. An enrollee, policyholder or insured under a policy issued by an insurer to the department of health and family services under s. 49.45 (2) (b) 2. to provide prepaid health care to medical assistance recipients is not liable for health care costs that are covered under the policy.

609.91(2) Prohibited recovery attempts. No person may bill, charge, collect a deposit from, seek remuneration or compensation from, file or threaten to file with a credit reporting agency or have any recourse against an enrollee, policyholder or insured, or any person acting on their behalf, for health care costs for which the enrollee, policyholder or insured, or person acting on their behalf, is not liable under sub. (1) or (1m).

609.91(3) Deductibles, copayments and premiums. Subsections (1) to (2) do not affect the liability of an enrollee, policyholder or insured for any deductibles, copayments or premiums owed under the policy or certificate issued by the health maintenance organization insurer or by the insurer described in sub. (1m).

609.91(4) Conditions not affecting the immunity. The immunity of an enrollee, policyholder or insured for health care costs, to the extent of the immunity provided under this section and ss. 609.92 to 609.935, is not affected by any of the following:

609.91(4)(a) An agreement, other than a notice of election or termination of election in accordance with s. 609.92 or 609.925, entered into by the provider, the health maintenance organization insurer, the insurer described in sub. (1m) or any other person, at any time, whether oral or written and whether implied or explicit, including an agreement that purports to hold the enrollee, policyholder or insured liable for health care costs.

609.91(4)(b) A breach of or default on an agreement by the health maintenance organization insurer, the insurer described in sub. (1m) or any other person to compensate the provider, directly or indirectly, for health care costs, including health care costs for which the enrollee, policyholder or insured is not liable under sub. (1) or (1m).

609.91(4)(c) The insolvency of the health maintenance organization insurer or any person contracting with the health maintenance organization insurer or provider, or the commencement or the existence of conditions permitting the commencement of insolvency, delinquency or bankruptcy proceedings involving the health maintenance organization insurer or other person, including delinquency proceedings, as defined in s. 645.03 (1) (b), under ch. 645, despite whether the health maintenance organization insurer or other person has agreed to compensate, directly or indirectly, the provider for health care costs for which the enrollee or policyholder is not liable under sub. (1).

609.91(4)(cm) The insolvency of the insurer described in sub.

(1m) or any person contracting with the insurer or provider, or the commencement or the existence of conditions permitting the commencement of insolvency, delinquency or bankruptcy proceedings involving the insurer or other person, including delinquency proceedings, as defined in s. 645.03 (1) (b), under ch. 645, despite whether the insurer or other person has agreed to compensate, directly or indirectly, the provider for health care costs for which the enrollee, policyholder or insured is not liable under sub. (1m).

609.91(4)(d) The inability of the provider or other person who is owed compensation for health care costs to obtain compensation from the health maintenance organization insurer, the insurer described in sub. (1m) or any other person for health care costs for which the enrollee, policyholder or insured is not liable under sub. (1) or (1m).

609.91(4)(e) The failure of a health maintenance organization insurer to comply with s. 609.94.

609.91(4)(f) Any other conditions or agreements, other than a notice of election or termination of election in accordance with s. 609.92 or 609.925, existing at any time.