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Waiving Co-Pys

  1. #1
    Modesto California
    Question Waiving Co-Pys
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    We recently had a doctor join our facility after closing his own practice. Many of his patients followed him here. He waived their co-pays and we will not. We called Blue Cross and they told us it was illegal not to collect the co-pay and it is a violation of our contract with them? Has anyone else verified that not collecting the co-pay is illegal and/or a contract violation?

  2. #2
    Cool Contract Violation
    It is definately a contract violation. According to most payer contracts, a reasonable effort must be made to collect on copays, coinsurance, and/or deductibles. If the provider fails to do so then they are seen as creating an 'unfair playing field' for other providers. Most contracts have stipulations as in to what is considered a 'reasonable effort' on attempting to collect from a patient.
    I have a provider out of Hawaii who does this constantly. His contract goes as far as stating that if they were to become aware of this (i.e. him giving 20% breaks on bills), that they (HMSA) would pursue him and require that he extend that discount to them in addition to their already discounted rates. The best I've been able to accomplish with him is to send him all the publications that tell him what he is exposing himself to for breach of contract however it is his practice and he makes the final call on write-offs.
    Good luck!

  3. Default
    I totally agree you should not be writing of balances unless you can prove finacial hardship!!! when audtiors come in and ask for charts they also ask for superbills of what the patient has paid!!! (at least that was my personal experince) We go as far as to take tax returns and make copys of them so that we can prove finacial hardship.

  4. Red face copays
    No wonder his patients followed him!

    Actually - the doctor - by waiving the patient's copay is truly giving the patient a 100% discount on his portion of the bill - because the patient is paying nothing - so in turn the insurance company is entitled to the exact discount that was given to the patient. A 100% discount to the insurance company - would mean that they are also entitled to pay "nothing" as well - so you would not be billing either party! (That's free medical care). I believe that if there have been reasonable attempts to collect the copay - that it may be written off as a bad debt eventually - but I wouldn't even go that route because it creates a pattern and it's just not worth it. If the doctor wants to provide free medical care - let him do it somewhere else and NOT under your Tax ID.

    The doctor AND the patient are in breach of their contracts with the Insurance Company. Since this doctor left his private practice to join your group - the contract is no longer between "him" and the insurance company.... it would be the entire practice that is liable for his actions....something to think about.

    Keep your stance on this. You are correct.
    Last edited by kellyross; 08-11-2010 at 02:24 PM.

  5. #5
    I have also heard somewhere (at a conference) that if the insurance companies find out that the copays are not being collected that the insurance company can drop the patient from coverage.

  6. #6
    Modesto California
    thanks so much everyone . I knew I was right,

  7. #7
    North Carolina
    I agree with the previous comments. Routinely waiving the copay is viewed as misstating the actual charge. There may be scenarios that waiving a copay can be justified but routinely waiving them can not. Although this is a Medicare citation, most carriers view CMS as the industry standard. Below is the introductory statement to Medicare's view.

    Why Is it Illegal for ``Charged-Based'' Providers, Practitioners and Suppliers to Routinely Waive Medicare Copayment and Deductibles?
    Rebecca CPC, CPMA, CEMC

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