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The truth about copays

Many people get very confused with the different ways insurance companies process claims and how they calculate what a patient owes. It is crucial that providers have someone in their office or a good billing service who knows how to read the explanation of benefits and is billing patients correctly.

Many plans today have a direct copay that is due at the time of service. Sometimes the copay is different for the patient’s PCP than it is for a specialist, but it is still a direct copay. For example, if a patient goes to his regular doctor for an asthma checkup or physical, he pays $15 but if he goes to a podiatrist or chiropractor the copay is $25. In either case, the patient is generally charged and willing to pay the copay at the time of their visit.

Many of the insurance companies print the patient’s copay information directly on their ID card. It will say PCP copay $15 Specialist copay $25, or whatever. Some do not print copays on the card. Usually the patient knows what it is, but some patients don’t realize they have a higher copay for specialists. It is a good idea to call the insurance company to verify a copay if this is a new patient. Especially if you are billing a specialist.

Most offices will ask for the copay when the patient checks in, which is a good idea. There may not be a good chance to get it on the way out. For example, if the patient does not need to be seen again, the patient may not even need to stop at the desk. Or if he’s not feeling well and spends an hour and a half in the office, he probably just wants to get out of there. It is a very good idea to collect the copay when the patient registers. Eliminates the need to bill a patient later if he leaves without paying the copay.

Sometimes patients do not want to pay the copay. Copays are due at the time of service in accordance with most contracts that insurance companies require the provider to sign in order to be in their network. It is not the providers who establish that rule. If the patient really doesn’t have any money, then it’s okay to give them a break and let them bring it in another time or bill you. I went to the ER once with a urinary tract infection. I was in agony and when I got there I realized that I had forgotten my bag. They were kind enough to see me even though I couldn’t pay my copay and didn’t even have my insurance card. I stopped by later that day with the card and copay.

Since it’s best to collect your copay up front, you should definitely try to get it right then. But if you are going to allow the patient to be seen without paying the copay, you need to let the patient know that you are doing them a favor. If you have pre-addressed envelopes with the office address, it is a good idea to give one to the patient to send the copay. They are more likely to mail it if they have a pre-printed envelope.

Many providers do not realize that they are actually breaking their contract with the insurance company if they do NOT charge the patient the copay. If a provider doesn’t collect copays regularly and an insurance company finds out, they can terminate the provider’s contract. Actually, this is a great tool for patients who are trying to avoid paying the copay. The provider can tell them that if they find out without collecting the copay, they can be dropped from the patient’s plan.

If you have a patient with a hardship case and the provider is going to waive a copay, or waive all copays for a period of time, then the patient’s record needs to be well documented. For example, a patient’s husband was in a serious car accident and is out of work for a period of time, and the provider decides to forgive copayments while the husband is out of work. The patient’s record must clearly indicate why copays are not charged. Provide details, such as “Pt’s husband has a car account on 8/3/08 and is out of work indefinitely. He only makes 50% salary. He has 5 children.” Or whatever the case.

Of course, there are always patients who do not have to pay their copays. The cousin of the patient’s wife, the son of the doctor’s roommate in college, etc. Most insurance companies will allow a couple of cases without bothering too much, but they definitely frown on skipping copays on too many patients. Providers should be specific about who they give breaks to.

Simply put, copays actually work better for a provider because they know up front what the patient’s responsibility will be and can collect it before seeing the patient. It is always easier to get paid upfront than to have to bill the patient. Make sure the person registering the patient is consistent in collecting copays.


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