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Ohio Laws and Rules
Chapter 4769: BALANCE BILLING OF MEDICARE BENEFICIARIES
As used in this chapter:
(A) "Medicare" means the program established by Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301 , as amended.
(B) "Balance billing" means charging or collecting from a medicare beneficiary an amount in excess of the medicare reimbursement rate for medicare-covered services or supplies provided to a medicare beneficiary, except when medicare is the secondary insurer. When medicare is the secondary insurer, the health care practitioner may pursue full reimbursement under the terms and conditions of the primary coverage and, if applicable, the charge allowed under the terms and conditions of the appropriate provider contract, from the primary insurer, but the medicare beneficiary cannot be balance billed above the medicare reimbursement rate for a medicare-covered service or supply. "Balance billing" does not include charging or collecting deductibles or coinsurance required by the program.
(C) "Health care practitioner" means all of the following:
(1) A dentist or dental hygienist licensed under Chapter 4715. of the Revised Code;
(2) A registered or licensed practical nurse licensed under Chapter 4723. of the Revised Code;
(3) An optometrist licensed under Chapter 4725. of the Revised Code;
(4) A dispensing optician, spectacle dispensing optician, contact lens dispensing optician, or spectacle-contact lens dispensing optician licensed under Chapter 4725. of the Revised Code;
(5) A pharmacist licensed under Chapter 4729. of the Revised Code;
(6) A physician authorized under Chapter 4731. of the Revised Code to practice medicine and surgery, osteopathic medicine and surgery, or podiatry;
(7) A physician assistant authorized under Chapter 4730. of the Revised Code to practice as a physician assistant;
(8) A practitioner of a limited branch of medicine issued a certificate under Chapter 4731. of the Revised Code;
(9) A psychologist licensed under Chapter 4732. of the Revised Code;
(10) A chiropractor licensed under Chapter 4734. of the Revised Code;
(11) A hearing aid dealer or fitter licensed under Chapter 4747. of the Revised Code;
(12) A speech-language pathologist or audiologist licensed under Chapter 4753. of the Revised Code;
(13) An occupational therapist or occupational therapy assistant licensed under Chapter 4755. of the Revised Code;
(14) A physical therapist or physical therapy assistant licensed under Chapter 4755. of the Revised Code;
(15) A professional clinical counselor, professional counselor, social worker, or independent social worker licensed, or a social work assistant registered, under Chapter 4757. of the Revised Code;
(16) A dietitian licensed under Chapter 4759. of the Revised Code;
(17) A respiratory care professional licensed under Chapter 4761. of the Revised Code;
(18) An emergency medical technician-basic, emergency medical technician-intermediate, or emergency medical technician-paramedic certified under Chapter 4765. of the Revised Code.
Effective Date: 03-18-1997
As used in this chapter:
(A) "Medicare" means the program established by Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended.
(B) "Balance billing" means charging or collecting from a medicare beneficiary an amount in excess of the medicare reimbursement rate for medicare-covered services or supplies provided to a medicare beneficiary, except when medicare is the secondary insurer. When medicare is the secondary insurer, the health care practitioner may pursue full reimbursement under the terms and conditions of the primary coverage and, if applicable, the charge allowed under the terms and conditions of the appropriate provider contract, from the primary insurer, but the medicare beneficiary cannot be balance billed above the medicare reimbursement rate for a medicare-covered service or supply. "Balance billing" does not include charging or collecting deductibles or coinsurance required by the program.
(C) "Health care practitioner" means all of the following:
(1) A dentist or dental hygienist licensed under Chapter 4715. of the Revised Code;
(2) A registered or licensed practical nurse licensed under Chapter 4723. of the Revised Code;
(3) An optometrist licensed under Chapter 4725. of the Revised Code;
(4) A dispensing optician, spectacle dispensing optician, contact lens dispensing optician, or spectacle-contact lens dispensing optician licensed under Chapter 4725. of the Revised Code;
(5) A pharmacist licensed under Chapter 4729. of the Revised Code;
(6) A physician authorized under Chapter 4731. of the Revised Code to practice medicine and surgery, osteopathic medicine and surgery, or podiatry;
(7) A physician assistant authorized under Chapter 4730. of the Revised Code to practice as a physician assistant;
(8) A practitioner of a limited branch of medicine issued a certificate under Chapter 4731. of the Revised Code;
(9) A psychologist licensed under Chapter 4732. of the Revised Code;
(10) A chiropractor licensed under Chapter 4734. of the Revised Code;
(11) A hearing aid dealer or fitter licensed under Chapter 4747. of the Revised Code;
(12) A speech-language pathologist or audiologist licensed under Chapter 4753. of the Revised Code;
(13) An occupational therapist or occupational therapy assistant licensed under Chapter 4755. of the Revised Code;
(14) A physical therapist or physical therapy assistant licensed under Chapter 4755. of the Revised Code;
(15) A licensed professional clinical counselor, licensed professional counselor, social worker, or independent social worker licensed, or a social work assistant registered, under Chapter 4757. of the Revised Code;
(16) A dietitian licensed under Chapter 4759. of the Revised Code;
(17) A respiratory care professional licensed under Chapter 4761. of the Revised Code;
(18) An emergency medical technician-basic, emergency medical technician-intermediate, or emergency medical technician-paramedic certified under Chapter 4765. of the Revised Code.
Amended by 130th General Assembly File No. TBD, HB 232, §1, eff. 7/10/2014.
Effective Date: 03-18-1997
No health care practitioner, and no person that employs any health care practitioner, shall balance bill for any supplies or service provided to a medicare beneficiary.
Effective Date: 11-24-1995
(A) The department of health shall receive complaints alleging violations of section 4769.02 of the Revised Code.
(B) The department shall make findings regarding complaints of alleged violations of section 4769.02 of the Revised Code. The department shall not make findings until after doing all of the following:
(1) Investigating the complaint and determining that there is a reasonable basis for it;
(2) Giving notice to the person named in the complaint and affording a period of ten days following issuance of the notice during which the person may correct an alleged violation by reimbursing the medicare beneficiary or crediting the beneficiary's account in an amount specified by the department;
(3) If the person named in the complaint does not choose to correct the alleged violation, giving the person notice and a reasonable opportunity for an adjudication hearing in accordance with Chapter 119. of the Revised Code.
(C) When the department finds, pursuant to division (B) of this section, that section 4769.02 of the Revised Code has been violated, the department may do any of the following:
(1) Publicly reprimand the violator;
(2) Issue an adjudication order requiring the violator to repay the medicare beneficiary an amount equal to the difference between the amount reimbursable under medicare and the payment received, plus interest on that amount at the rate prescribed under section 5703.47 of the Revised Code, from the date the beneficiary made payment until the date of the repayment;
(3) Issue an adjudication order imposing a penalty of five hundred dollars.
(D) When the department finds, pursuant to division (B) of this section, second and subsequent violations of section 4769.02 of the Revised Code by the same person, the department shall, in addition to imposing the penalties authorized by division (C) of this section, issue an adjudication order imposing a penalty of two thousand dollars for each violation subsequent to the first violation.
(E) If a violator of section 4769.02 of the Revised Code waived the right to a hearing under division (B)(3) of this section, the department shall reduce any monetary penalties imposed under division (C)(3) or (D) of this section by at least thirty-five per cent.
(F) If a violator is a corporation or partnership, an adjudication order under division (C) or (D) of this section may be issued to any corporate officer, any general partner, and any health care practitioner who is found pursuant to the investigation or hearing conducted under division (B) of this section to have had knowledge of, should have known of, or to have knowingly participated in a violation of section 4769.02 of the Revised Code.
(G) No penalty imposed under this section is cause to limit, deny, suspend, revoke, or deny the renewal of the license, certification, or registration of a health care practitioner; to refuse to license, certify, register, or reinstate an applicant for licensure, certification, or registration as a health care practitioner; to place a health care practitioner on probation; or, except as provided in divisions (C) and (D) of this section, to reprimand a health care practitioner.
Effective Date: 11-24-1995
(A) Health care practitioners and their employers shall make available to the department of health to inspect and copy, medical, professional, financial, and business records that are reasonably related to determining whether the practitioner or employer has violated section 4769.02 of the Revised Code.
(B) No person shall fail to comply with division (A) of this section.
Effective Date: 01-14-1993
In investigating possible violations of section 4769.02 of the Revised Code or conducting hearings under section 4769.03 of the Revised Code, the department of health may administer oaths, order the taking of depositions, and issue subpoenas compelling attendance of witnesses or production of documents. The subpoenas shall be served in the same manner as subpoenas and subpoenas duces tecum issued for a trial of a civil action in a court of common pleas. The department shall pay each witness who appears before the department in obedience to a subpoena the fees and mileage provided under section 119.094 of the Revised Code . If a person who is served a subpoena fails to attend a hearing or to produce documents, or refuses to be sworn or to answer any question put to the person, the department may apply to the court of common pleas of the county in which the person resides, or the county in which the hearing under division (B) of section 4769.03 of the Revised Code is conducted, for a contempt order, as in the case of a failure of a person who is served a subpoena issued by the court to attend or to produce documents or a refusal of such person to testify.
Effective Date: 01-14-1993; 2008 HB525 07-01-2009
The department of health shall conduct all investigations and hearings under section 4769.03 of the Revised Code in a manner that protects patient confidentiality. The department shall not make public the names or other identifying information about a patient unless the patient consents . Consent is not required for the release of the information if the department determines that it possesses reliable and substantial evidence that no bona fide health care practitioner-patient relationship exists. When the department publicly reprimands a violator pursuant to division (C)(1) of section 4769.03 of the Revised Code, it shall not make public the name or any other identifying information about a patient.
Effective Date: 11-24-1995
In the case of a violator of section 4769.02 of the Revised Code who elected a hearing under division (B) of section 4769.03 of the Revised Code, an adjudication order issued under division (C) or (D) of section 4769.03 of the Revised Code may, in addition to imposing the penalties specified in those divisions, require the violator to pay the reasonable costs, not exceeding twenty-five thousand dollars, of the investigation and adjudication conducted under division (B) of that section. If a health care practitioner or employer elected a hearing under division (B) of that section and was found not to have violated section 4769.02 of the Revised Code, the department of health may pay the health care practitioner's or employer's reasonable costs, not to exceed twenty-five thousand dollars, including attorneys' fees, associated with the conduct of the investigation and adjudication. Notwithstanding section 119.12 of the Revised Code, the filing of a judicial appeal of an adjudication order issued under section 4769.03 of the Revised Code shall operate as a suspension of the adjudication order pending the outcome of the appeal.
Effective Date: 01-14-1993
Unless a judicial appeal is pending, all monetary penalties imposed under division (C)(3) or (D) of section 4769.03 of the Revised Code and all costs ordered to be paid pursuant to section 4769.08 of the Revised Code shall be paid to the department of health not later than thirty days after the department issues the adjudication order imposing the penalties or ordering the payment of costs. The department shall deposit the penalties and recovered costs into the state treasury to the credit of the general operations fund created by section 3701.83 of the Revised Code. The penalties and recovered costs shall be used solely to administer and enforce this chapter.
Effective Date: 07-01-1993
The department of health shall notify the attorney general if any person fails to comply with a repayment order issued under division (C)(2) of section 4769.03 of the Revised Code. On receipt of the notice, the attorney general may, on behalf of the medicare beneficiary the person was ordered to repay, commence a civil action in the court of common pleas of Franklin county, the county in which the person resides, or the county in which the person's principal place of business is located to obtain a judgment ordering the person to repay the amount specified in division (C)(2) of section 4769.03 of the Revised Code plus the interest specified in that division. If the court determines that the department made the finding that the person violated section 4769.02 of the Revised Code after complying with division (B) of section 4769.03 of the Revised Code, the court shall order the person to make the repayment. If any person fails to pay, by the deadline specified in section 4769.09 of the Revised Code, a monetary penalty imposed under division (C)(3) or (D) of section 4769.03 of the Revised Code or costs ordered to be paid pursuant to section 4769.08 of the Revised Code, the department shall certify the amount due to the attorney general in accordance with section 131.02 of the Revised Code, and the attorney general shall collect the penalty or costs in accordance with that section.
Effective Date: 11-24-1995