Wiki refunding copays

[Sherriginger]

When we credential new providers with insurance companies, there is a period of time where the patient is seen without the Doctor being credentialed and and we know we will most likely have to write off the charge. We collect copays at the time of the visit. My question is, if we don't bill the insurance company because it is past the timely filing limit, or we bill them and they deny, can we keep the patient copay or should it be refunded to the patient? My thought is that the copay is the amount the insurance company imposes in the contract with the patient. If the insurance does not pay we should not keep the copay. Thanks for any help with this!

 

[Melissa Harris CPC]

You must refund the copayment collected on the services provided by a non-credentialed physician. You may not bill the patient for these services unless the patient is informed previously and signs a waiver agreeing to pay for the service out of pocket because the provider is not credentialed. Collecting copays is fraud in this case. The charges must be written off for these services.

Hope this helps....

Melissa Harris, CPC
The Albany and Saratoga Centers for Pain Management

 

[austin408]

Your posts brought up a few questions for me. Any insight you or anyone else could provide would be greatly appreciated!

Sherriginger - Why wouldn't the insurance company make the provider's "effective" date as a credentialed provider retroactive to when they starting seeing patients at your practice? In my experience, if your practice is billing the insurance company even though the provider is not currently active for the time of service, they should deny but then reprocess and pay for the services once the provider becomes credentialed, which would negate the need to refund any copays to patients. Is this not the case?

Melissa Harris - you stated that it would be fraud to keep the copays for services provided by a non-credentialed physician, would this also be the case if neither the provider nor the practice/facility were contracted/participating/credentialed with the plan?