copays/allowed amounts

[caoberster]

Hi, Quick question, I am a chiropractor and we have someone inhouse who does billing thru our software.  Unfortunately we are all learning as we go.. Recently I have noticed alot of credits in patients accounts and it concerned me.When I asked what they were about, some are ligitimate and the others I am not sure, but obviously we need to find out what is the correct and legal answer so we can make sure we are doing the right thing ASAP to make sure we do not get ourselves into some trouble! Is it correct that if somebody has a copay of $50, and the EOB comes back that the insurance company is not paying anymore as the allowed amount is $32 (some visits more some less), do we need to reimburse the patient the $18, because they paid 50 copay and the allowed amount that date of service was only 32?  I thought the copay was the copay and they have agreed to pay that when they signed up for whatever particular insurance, if we get more happy days and if  we don't we accept their copay as payment in full (per say) writing off whatever else was billed and was not paid by the insurance company...  PLEASE HELP!  I am not sure if it matters but we are in the state of Georgia...

Thank you so much for any insight! 

[Merry]

It depends on if you are in contract with that insurance company. (in network). How do you know what the co-pay is? Is it on the back of the card? Can you go online to verify eligibility and benefits? Are there different co-pays for different specialties within the network. (not unusual at all).
And so many insurance companies limit  chiropractic services so if they do not, for example, cover x-rays and you do the x-rays, you would have the patient pay for that out of pocket and it would have no bearing on the insurance coverage. Also, some carriers limit certain diagnosis codes in order for you to get paid.

Can you be specific and give us an idea for a patient in question without disclosing any PHI? Lets see if we can help you.

Merry

[DMK]

This is really easy.  If the allowed amount for a date of service is $23.73, and the patient's co-pay is $25.00, they are only responsible for $23.73. 

If you services that make the allowed amount OVER $25.00, they would be responsible for the full $25.00 and the insurance should pay the rest UNLESS there's deductible to be met (which supercedes the co-pay) OR there's a co-insurance as well as co-pay.

For example:

The doctor performed the following services:

98940 CMT 1-2 Areas (allowed amount is   $22.41)
97012 Mechanical Traction (allowed amount is $9.17)

Total visit allowed amount is                      $31.58
Patient's co pay is $25.00                        ($25.00)

Insurance should pay                                $6.38

If the doctor ONLY did the CMT the patient ONLY pays the allowed $22.41 (regardless if the co-pay on the plan is $25.00, there wasn't $25.00 worth of service performed.

If the patient has a $25.00 co pay and 20% co insurance (and we have a few of these) they would pay $25.00 + $1.31 and the insurance would pay $5.07.

If the total service was only $22.41, the patient ONLY pays the $22.41.

And remember, deductible comes first.  Never mind the co-pay.  If there's deductible to be met, they owe the $31.58.

Sorry if this looks like a high school math problem.  It's not.  And the better you as the biller grasps the order of what the patient owes, the better you can explain it to the doctor and the patient.

Luckily, in chiropractic, you tend to bill for the same services and you'll get to know what the allowed amounts are for each insurance company (you might want to create a little cheat sheet).  That way you can let the patient know right up front what they will owe.  They'll get in the habit of paying at time of service and there won't be any surprises when the statement comes, or they'll never have to be sent a statement because the office will collect the patient portion at time of service.

Hope that helps, and that I'm not coming across badly! 

[rdmoore2003]

This is really easy.  If the allowed amount for a date of service is $23.73, and the patient's co-pay is $25.00, they are only responsible for $23.73. 

If you services that make the allowed amount OVER $25.00, they would be responsible for the full $25.00 and the insurance should pay the rest UNLESS there's deductible to be met (which supercedes the co-pay) OR there's a co-insurance as well as co-pay.

Exactly, DMK

[caoberster]

Thank you all so much!  I knew about the x-ray part, if it is something that is outwardly not covered by the ins co, then the patient is responsible... it was the allowed amounts being under the co-pay and reimbursment of any paid over that I was unsure about... I have been out of the states for many years and never had to deal with insurance as a consumer, and insurance in England is COMPLETELY different so even as a Dr I am having to learn it all over again!  I am very greatful to have found this sight and for your quick responses!  I'm sure this won't be the last question I ask!! and NO, DMK, you did not come across bad, it was a great example and spelled out very clearly so it was super easy to understand! thanks again!

[Billing2]

We have been running in to this a lot lately, with co-pays being so high. We have been told by many insurances to have the patient sign a letter that the co-pay is more than the allowed amount and put it in there chart to show in compliance with collecting co-pays.
I have been having my office do this. I use the letter from the NPCC and it works very well.

[PMRNC]

We have been running in to this a lot lately, with co-pays being so high. We have been told by many insurances to have the patient sign a letter that the co-pay is more than the allowed amount

Copay more than allowable? Never seen that one yet. Seen deductibles and coinsurance more but not copay's

Easy way to remember is U&C/R&C cuts to reimbursement are patient responsibility and "adjustments" are not (contracted providers)

[DMK]

MD's shouldn't have an allowable that is more than the co-pay, but it happens often in Chiropractic since our services are reimbursed at pretty low levels.  Even a $25.00 copay is more than the allowable for a 98940 or 98941 for Blue Cross (we get $22.41)

[PMRNC]

Ouch.. yet another reason I don't bill chiropractic. LOL

[Merry]

Even a $25.00 copay is more than the allowable for a 98940 or 98941 for Blue Cross (we get $22.41)>>

Live and learn. Never ran into this but then, this is what this board is all about

Merry