Current through Supplement No. 394, October, 2024
Any arrangement or agreement between a chiropractor and a
patient for a course of future treatment for which funds in an amount of five
hundred dollars or more during any twelve month period are collected in advance
of these services shall be considered a prepaid care plan within the meaning of
this section. Services under a prepaid care plan may cost less than if the
services were purchased individually. The reduction in cost must bear a
reasonable relationship to the expense avoided by the provider due to reduced
accounting and debt collection activities in accordance with Office of
Inspector General (OIG) Advisory Opinion 08-03, regarding prompt payment
discount. The prepaid care plan may provide for either an annual or monthly fee
out of pocket. A chiropractor who offers such a plan is subject to the
following requirements:
1. Escrow
account. A designated escrow account insured by the FDIC shall be established
for deposit of all funds received in connection with the prepaid care plan.
Such funds may not be commingled with a chiropractor's personal or business
account.
a. All instruments, including checks
and deposit slips, must bear the phrase "Escrow Account."
b. The chiropractor shall maintain a clear
accounting of all funds received, including date and from whom the funds were
received.
c. The chiropractor shall
maintain a clear accounting of all disbursements including the dates and to
whom the disbursements were made, and to which patient the disbursements are to
be applied or accounted for.
d. If
a patient's deposit in the escrow account earns in excess of five dollars
during a twelve-month period, the interest must be paid or credited to the
patient by the end of the period.
e. No more than one account is required
regardless of the number of prepaid plans maintained by the
chiropractor.
f. Funds may only be
transferred out of the escrow account for the following reasons:
(1) After services, goods, or appliances have
been provided to the patient, and only in the usual and customary amounts
specifically related to the services, goods, or appliances provided.
(2) To reimburse the patient any amounts owed
following a notice by either the patient or the chiropractor to terminate the
prepaid plan. Any amounts must be transferred according to the written
agreement.
(3) Payment to the
patient of interest earned when it exceeds five dollars per twelve month
period.
g. The
chiropractor shall cause a reconciliation of the escrow account to be made no
less than quarterly, with a copy provided to the patient, and shall retain a
copy of the reconciliations and all supporting documents for no less than seven
years.
2. Written plan.
All prepaid care plans require a written plan, signed by both the chiropractor
and the patient, with a copy maintained in the patient's record and a copy
provided to the patient, and must include at least the following:
a. A list of all services, goods, and
appliances which are covered by the plan.
b. A list of all fees related to the services
described in the plan.
c. A
statement that an accounting can be requested by the patient at any time. This
accounting must:
(1) Be provided to the
patient within five working days of a written or verbal request; and
(2) Itemize all fees used to calculate any
reimbursement.
d. An
explanation of the reimbursement policies and formula that are used in
returning unused funds to the patient in the event of early termination by
either the chiropractor or the patient.
e. An explanation of any policy modifying the
plan in the event of a injury, such as an auto injury or work-related injury or
in the event of extended absence or new illness. These explanations must be
separately initialed by the patient.
f. A provision that the patient will be
notified in writing when the patient's account reaches a zero
balance.
g. A statement that
indicates the chiropractor makes no claim or representation that a particular
treatment, procedure, or service, or any combination of treatments, procedures,
or services, is guaranteed to result in a particular clinical
outcome.
h. A statement that the
patient has the right to cancel the prepay plan without penalty within three
business days of entering into the plan by submitting a written and signed
cancellation notice, and upon the chiropractor's receipt of the cancellation
notice, the chiropractor shall have seven working days to fully refund any
unused funds to the patient. This right of cancellation may not be waived or
otherwise surrendered.
3. Early termination. The patient has the
right to terminate the prepaid plan at any time; under such circumstances as
completing care early, moving, or a new injury or illness. The chiropractor may
terminate the prepaid plan at any time, for good and sufficient cause, except
the chiropractor must ensure that patient abandonment does not occur.
a. In event of early termination of a prepaid
plan by the patient, the maximum fee charged cannot exceed the chiropractor's
usual and customary fee for services rendered.
b. In event of early termination of a prepaid
plan by the chiropractor, any cost reduction for the package of services must
be prorated when determining the amount of repayment.
c. In event of early termination of a prepaid
plan, the fee for the unused portion must be returned with no
penalty.
4. Prepaid
plans must be compliant with all applicable state and federal laws.
5. When providing care as a part of a prepaid
plan a chiropractor shall provide competent, necessary care in a timely and
professional manner. All care recommended and rendered must be clinically
justified and appropriately documented.
6. A prepaid plan is not health insurance and
does not meet the Affordable Care Act "individual mandate" requirements for
health insurance coverage.
7. The
regulations in this section do not release a chiropractor from any contractual
obligations that the chiropractor has with an insurer or other entity. A
chiropractor who is contracted with an insurance carrier shall adhere to the
terms of their provider contract in regards to the collection of copayments,
co-insurances, and applied deductibles. A chiropractor may not bill a
reimbursement entity or a patient for any amount exceeding what is earned and
distributed to the chiropractor.
8.
Failure to abide with the requirements of this section is unprofessional
conduct.
General Authority: NDCC
28-32-02,
43-06-04(1) &
(6), 43-06-04.1.
Law Implemented: NDCC
43-06-04(6)(a)
& (g),
43-06-15(1)(e).
