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
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 .