Question Copays for claims denied for timely filing?

LisaJ0867

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I have searched and cannot find a straight answer on this. Any help would be greatly appreciated. I have worked in places that do both but I am hoping to find documentation that clearly states what is correct:
When a provider collects a copay at the time of service but the claim isn't submitted within the timely filing deadlines and gets denied; can the provider keep the copay or does it have to be refunded (or remain a credit on the patient's account)?
For providers that currently keep the copay for timely filing denials, do you bill for a copay that you failed to collect at the time of service?
 

ccollison

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Saginaw, MI
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Check your insurance carrier's contract. I bet there is something in it that says if the service is not submitted timely, no payment will be made. I don't think it's acceptable to collect and KEEP the copay if it's the provider's fault it is late. I think a refund is required.

C Collison CPPM, CPC. CPMA, CCC
 

Mayzoo

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Wills Point, TX
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Why should the patient benefit from the provider's mistake? They would have a copay whether the provider billed it timely or not.

It is just part of the contract the provider or their proxy signed. If the insurance company states the patient has no portion, then you cannot charge (keep) a patient payment. To do so is fraud.
 

SharonCollachi

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It is just part of the contract the provider or their proxy signed. If the insurance company states the patient has no portion, then you cannot charge (keep) a patient payment. To do so is fraud.

I don't sign contracts like that. Perhaps other people do in other offices. I also refuse contracts that don't allow us to charge for no-shows, and there are plenty of those out there as well.
 

LisaJ0867

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I don't sign contracts like that. Perhaps other people do in other offices. I also refuse contracts that don't allow us to charge for no-shows, and there are plenty of those out there as well.
Thank you for your feedback. So, if your front desk doesn't collect a copay, in error, on a patient that should pay one, and the visit doesn't get billed within the timely filing time frame, would you bill your patient and adjust the difference to timely filing? Or do you adjust the entire balance as timely filing?
 

SharonCollachi

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Thank you for your feedback. So, if your front desk doesn't collect a copay, in error, on a patient that should pay one, and the visit doesn't get billed within the timely filing time frame, would you bill your patient and adjust the difference to timely filing? Or do you adjust the entire balance as timely filing?

Our system would show this:

Insurance responsibility $150
Patient responsibility $50

We bill the patient for their copay, and we write off the $150 as untimely filing. And then have a discussion about how it happened so it won't happen again.
 
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ALBUQUERQUE, NM
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I have searched and cannot find a straight answer on this. Any help would be greatly appreciated. I have worked in places that do both but I am hoping to find documentation that clearly states what is correct:
When a provider collects a copay at the time of service but the claim isn't submitted within the timely filing deadlines and gets denied; can the provider keep the copay or does it have to be refunded (or remain a credit on the patient's account)?
For providers that currently keep the copay for timely filing denials, do you bill for a copay that you failed to collect at the time of service?
That is a common form of fraud. The reason it’s illegal is: 1. The EOB will always say “patient responsibility $0”
2. If the Dr keeps the copay, that amount never gets applied to the patient’s deductible and out of pocket maximum.
For high deductible plans, some places demand the estimated coinsurance up front. So if your deductible is $1500 and you pay before a CT scan, and they don’t send the claim in time but keep your payment, the insurance isn’t going to acknowledge that you’ve met your deductible and the next provider won’t know you’ve paid it either. It’s pretty much theft in my opinion. Even if it’s $50 copay for an office visit.
 

newbergt

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Newaygo, MI
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if your eob comes back from the insurance company as timely filing and it doesn't state a patient responsibility and you keep that money that the patient has paid your committing fraud. The patient will get an eob stating they owe nothing to that provider. If the patient has seen that eob and wants there money back you have no choice but to return it. Its no different that if an insurance company were to reprocess a claim and the original had a copay the reprocessed claim had none you have to return the money.
 
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