The truth about Copays

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

Many plans today have a fixed co-pay that is due at the time of service. Sometimes the copay is different for the patient’s primary care physician than for a specialist, but it’s still a regular copay. For example, if a patient goes to their regular doctor for an asthma checkup or physical exam, they pay $15, but if they go to a podiatrist or a chiropractor, the copay is $25. In either case, the patient is usually accustomed to and willing to pay the copay at the time of their visit.

Many insurance companies print the patient’s copay information directly on their ID card. It will say PCP pays $15. Specialist copay $25, or whatever. Some do not print the 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’s a good idea to call the insurance company to verify a copay if it’s a new patient. Especially if you invoice for 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 opportunity to get it on the way out. For example, if the patient no longer needs to be seen, he may not even need to stop at the counter. Or if they don’t feel well and sit in the office for an hour and a half, they probably just want to get out of there. It’s just a really good idea to collect the copay when the patient checks in. It eliminates the need to bill a patient later if they get out without paying the copay.

Sometimes patients don’t want to pay the copay. Copays are due at the time of service under most contracts that insurance companies require the provider to sign to be part of their network. It is not the providers who set that rule. If the patient really just doesn’t have any money, it’s fine to give them a break and let them put it in or bill it at another time. I went to the emergency room once with a urinary tract infection. I was in pain and when I got there I realized I forgot my wallet. They were nice enough to see me even though I couldn’t afford my copay and didn’t even have my insurance card. I came by later that day with the card and copay.

Since it is better to collect the copay in advance, you should definitely try to get it then. But if you want to show the patient without paying the copay, let the patient know that you are doing them a favor. If you have pre-printed envelopes with the office address on them, it’s a good idea to give one to the patient so they can mail the copay. They are more likely to post these if they have a pre-printed envelope.

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Many providers don’t realize that they are actually breaking their contract with the insurance company if they DO NOT charge the patient for the copay. If a provider regularly fails to charge for copays and an insurance company finds out, they can terminate the provider’s contract. This is actually a great tool to use for patients trying to get under the copay. The provider may tell them that if caught failing to charge the copay, they may be kicked out of the patient’s plan.

If you have a patient with a hardship case and the provider is going to forgive a copay, or forgive all copays for a period of time, the patient’s record should be well documented. For example, a patient’s husband was in a bad car accident and is out of work for a while, and the health care provider decides to forgive her copays while the husband is out of work. The patient’s record should clearly indicate why the copays are not being collected. Provide details such as “Pt’s spouse in auto acc on 8/3/08 and out of work indefinitely. Receives only 50% wages. Have 5 children.” Or whatever the case.

Of course, there are always the patients who don’t have to pay their copays. The nephew of the patient’s wife, the son of the doctor’s roommate, etc. Most insurance companies will allow a few cases without getting too angry, but they definitely frown on skipping over too many patients’ copays . Providers should be specific in who they give breaks.

Basically, copays actually work best for a provider because they know in advance what the patient’s responsibility will be and can collect it before they see the patient. It is always easier to get paid upfront than to bill the patient. Make sure the person checking in the patient is consistent about collecting the copays.