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Patient Copayments above the fee schedule

  1. Default Patient Copayments above the fee schedule
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    I know that if a patient's copay is higher than the fee schedule we only can charge the patient the lower amount, which is the fee schedule. My Doctor's seem to think we can charge the patient the higher copay of $50.00 knowing the insurance company fee schedule is going to stat $45.00 copay. Mr Doctor's are told that they are able to keep the difference of $5.00 because the patient has an agreement with the insurance company to pay $50.00. Can someone send me written proof that I am correct so I prove it to my bosses.

  2. #2
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    When you get the eob's from the insurance company it should show you what the allowable is and how much to charge the patient for the copay. I have never charged a patient more than the allowable. It is in your contract. If the copay is $50 but the allowable is $45 you should be collecting the $45. Your contract states you cannot charge the patient more than the allowable

  3. Default
    I know that but my Doctor's were told by another person that is not true, so I am trying to find something in writting that states that so I can prove them wrong

  4. #4
    Default
    Just let them know that if they have a contract with that insurance company (and they must if they have a fee schedule for them) then they have to follw the EOB received.

  5. #5
    Exclamation
    Quote Originally Posted by kellybolts@yahoo.com View Post
    I know that if a patient's copay is higher than the fee schedule we only can charge the patient the lower amount, which is the fee schedule. My Doctor's seem to think we can charge the patient the higher copay of $50.00 knowing the insurance company fee schedule is going to stat $45.00 copay. Mr Doctor's are told that they are able to keep the difference of $5.00 because the patient has an agreement with the insurance company to pay $50.00. Can someone send me written proof that I am correct so I prove it to my bosses.
    The patient's copay should be constant, regardless of the fee schedule - if their copay is always $45.00, then it's $45.00. The allowable amount is determined after the claim is received (even though you already know what your contracted rates are, coverage is only determined once the payor gets the claim). Your contract says that you will only get reimbursed for the allowable charges, period - not the allowable plus a copay; the copay is carved out of the allowed amount. Any difference below the allowable should be paid by he insurer, or billed to the patient, if it's applied to their deductible/coinsurance. So, if the allowable is $50 and the patient's copay is $45, you collect $45 from the patient at the time of service, file a claim, and either get the other $5 from the payor, or bill the patient for it once you receive the EOB.

    If the patient's copay is higher than the allowable, you will owe them a refund. You are not allowed to keep anything in excess of your contracted rate - that's called 'balance billing', and it's explicitly prohibited in the vast majority of physician/payor contracts. Only collect what you're allowed to before the visit - the regular copayment amount, and for the payors that allow it, any deductible amounts that the patient may be responsible for (check with payors on an individual basis to see if you can collect deductibles at the TOS). If the copayment is typically higher than the reimbursement, it may be time for your physician to renegotiate his contracts, but that doesn't mean he gets to keep the extra. Patients DO look at their EOB's, and all it will take is one of them to notice that they should have only been responsible for $45, and make a complaint to their insurer, before your provider finds himself in a mess of trouble for breaching his contract(s).

  6. #6
    Default Here are a few references...
    An internet search for 'balance billing' should give you sufficient references...here are a few I found...

    http://healthinsurance.about.com/od/...ce_billing.htm
    http://www.humana-military.com/south...ce-billing.asp

  7. Default Who recieves the refund?
    I have a billing manager who states that if a patient pays their copay and then the insurance pays the full allowable amount without applying that copay then we must refund the insurance the amount of the patients copay because the insurance processed the claim incorrectly. Is this true? I would think the refund would go to the patient.
    Our manager states that if the insurance were to come back and audit us we would owe.

  8. #8
    Default
    IF the insurance co processed the claim correctly, the patient is due a refund. Keep in mind things are different now that they were years back where a patient had a "set" copay and it was applied to pretty much any service. Now with coverages changing due to the ACA and preventitive things being paid at 100% with no pt deduct/copay due, pt's that paid a copay in all honesty are due it back. If a provider "knowingly" keeps money that are due back to patients he can get into a mess. I worked for a dr that had gotten over $21000.00 in money from patients and refused to cut refund checks. He told me "the patient can call here and request their money back". Which is unethical. And sad because many patients do not understand the billing process and provider contracts and so forth.
    Teresa Kelley, CPC
    Detroit, MI AAPC Chapter member

  9. Post Physicians Charging Extra Fees
    I have a question. A physician charges a $ 25.00 surcharge to all patients. The surcharge is charged to patients if the office staff has to bill the patient for there copay and deductibles. The charge isn't deducted from the copay or deductible amounts. It is an additional charge.
    Can physicians do this? I don't believe they can and I am trying to find the law or regulation that support that physicians can't. I need help please.
    Thank you,
    Lori Hoffman

  10. #10
    Default
    $25 seems a bit excessive, especially when a patient may not know where they are in a deductible situation. With today's high deductible plans, and HRA's and HSA's, it can be difficult to navigate. Some payers will send their claims files to the HRA or HSA vendor and the member can either auto-pay from the HRA/HSA site, pick-and-choose which claims to pay the cost-share on, choose to wait for the bill and write a check, or use their HRA/HSA debit card at point of service. I have seen the surcharge posted at various offices if they have to bill a copay, but not for the deductible.

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