Monday, October 28, 2013

You’ve sold it, now what happens…

Recently, co-blogger Bob V sent me a link from his list-serve that concerned co-payments:
I have a client, who currently has UHC RPPO, the copay is $0 for her PCP. I find out today that her Primary care doctor has been charging her a $35 copay every time she sees her. The doctor is clearly listed as a "Primary Care Physician" in the directory, and not a specialist, So I cannot figure out why she would get billed a copay like this. I have not had a chance to contact the doctor yet to investigate, but when I found this out, I was outraged, i wanted to go down to her doctor's office and demand they give her her money back.

While I admire this agent's chivalry, before he cold-cocks a doctor, maybe we should review the situation, beginning with: what is a co-payment? A co-payment is an amount of money a patient agrees to pay a physician for an appointment, as set by the insurance company, which the physician agrees to accept. These co-payments are to be collected at time of service, hopefully before the appointment ( but I digress). Some companies determine the co-payment by the type of provider (eg  Family Practice or Specialist) or by appointment type (eg Physical Therapy), or even a single co-payment regardless of the appointment type or provider. In this situation, the Family Practice Doctor was charging the higher Specialist co-payment to the patient.

Let’s assume that the doctor is collecting the higher co-payment. When the doctor electronically bills the insurance company for the appointment, the co-payment of $35.00 will be reflected in the bill, so the insurance company will know what the patient paid and the charge by the provider. If the co-payment is incorrect, the doctor will receive an EOB with the $35.00 taken out of his payment and probably a note reflecting that the insurance refunded the patient the $35.00. In the end the doctor still makes the same amount of money, and it will be reflected in the doctor’s practice management system that a co-payment is not due. Insurance companies are very competent in ensuring that doctors are not, in any way, overpaid for the services they render.

To be honest, unless this provider is practicing in the dark ages, without any type of electronic practice management system or EMR, this scenario does not often play out, for two reasons:
1) The HITECH Act, passed several years ago, outlines 20-plus meaningful uses that each physician’s office must adhere to in order to continue to get their Medicare monies. One of those meaningful uses is to verify insurance and the patient’s financial responsibility. This is then recorded into the software, and when the patient arrives with their insurance card and driver’s license and their paperwork filled out completely, then the patient is charged their co-payment as set by the insurance company.
2) Patients do not know much about their health insurance but they, by God, know how much their co-payment is and will REFUSE to pay one penny more than they owe; oftentimes they don’t even want to pay their co-payment, but again I digress.

So, I would not worry too much about the co-payment: the patient and the insurance will surely keep the doctor in line.
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