Routinely Waiving Copays May Be Fraud

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  • February 3, 2014
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In a healthcare environment where every penny is scrutinized, it’s hard to believe some practices waive copays completely, or offer “insurance-only” payments.
If you’ve been known to let copays “slide,” and don’t follow up with letters requesting patient payment, you could be bringing on trouble. Insurance carriers have been increasing collection efforts for copays, deductibles, and coinsurance.
According to Medical Economics®:

Providers who waive copays are exposed to HIPAA risk because, arguably, the provider is misstating his or her charge to the commercial plan. For example, assume a $100 total charge where the patient has an 80/20 plan. If the provider waives the patient’s obligation to pay 20%, then, again arguably, the commercial plan owes only 80% of $80.

Physicians who forgive their unpaid patients argue that enforcing copay collection goes against the grain of the American Medical Association’s (AMA) “Code of Medical Ethics,” Opinion 8.03: “The primary objective of the medical profession is to render service to humanity; reward or financial gain is a subordinate consideration.”
AMA’s Opinion 6.12, however, does not condone waiving of copays because it may be considered to be fraud:

A number of clinics have advertised their willingness to provide detailed medical evaluations and accept the insurer’s payment but waive the copayment for all patients.

Physicians should be aware that forgiveness or waiver of copayments may violate the policies of some insurers, both public and private; other insurers may permit forgiveness or waiver if they are aware of the reasons for the forgiveness or waiver. Routine forgiveness or waiver of copayments may constitute fraud under state and federal law. Physicians should ensure that their policies on copayments are consistent with applicable law and with the requirements of their agreements with insurers.

Physicians who offer “insurance-only” payments, might reconsider advertising in such a way implicating possible Anti-kickback violations. This may cause suspicion for the Office of Inspector General (OIG), who says regularly waiving copays may be considered criminal kickback in Medicare cases.
What You Can Do?
Because insurance companies have only recently been emphasizing collection of copays, you have time to rectify the situation if you’ve been lax about collection in the past. Come up with a corrective plan, be sure you keep records of your attempts to collect copays, and contact your insurance carriers about their policies. If you don’t, you may find affected carriers demanding refunds for paid patient benefits.
Source: Physicians Practice, “Forgiving Patient Copays Can Lead to Unforgiving Consequences”

Michelle Dick
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Michelle A. Dick, BS, is a freelance content specialist, providing writing, editorial expertise, and graphic imagery to clients. Prior to becoming a free agent, she was an executive editor for AAPC, editor-in-chief at Eli Research, and editor at Element K Journals. After earning a Bachelor of Science from the State University of New York at Buffalo State, Dick entered the publishing industry as a graphic artist, ad coordinator, and web designer for White Directory Publishers, Inc.

No Responses to “Routinely Waiving Copays May Be Fraud”

  1. Rebecca Armenta says:

    This does not apply if you are a Federally Qualified Health Care (FQHC) Center.

  2. Cris says:

    Would this not apply to RHCs as well?

  3. Don Siedenburg says:

    The nursing home my wife entered started giving her Physical Therapy Treatments and billed Medicare without my knowledge or consent. When I got the first Medicare Summary Notices for three months the co-pay was $950.00. I went to the administrator and told her that I would pay the $950.00 but wanted the Physical Therapy treatments stopped. The administrator told me that if I consent to continue the PT’s, she would waive the $950.00 co-pays and any future co-pays and I agreed. Now I find out this is a crime. Any suggestions out there?