Author Topic: Copays over contracted allowances  (Read 4254 times)

BH7743SS

  • Newbie
  • *
  • Posts: 1
Copays over contracted allowances
« on: February 08, 2012, 03:32:30 PM »
Office Mgr for Chiropractor increasingly running into copay above contracted allowed amounts, meaning the patient actually has NO coverage (i.e.  BCBS copay = $ 40.00 - but contract only allows 28.00 in AZ & no other charges allowed) thus the patient pays 40 and insurance $0 OR patient pays $28.00 and still insurance pays zero- depending on who you talk to about how to handle this.  But either way the patient or employer has been sold a policy indicating chiropractic coverage, where none actually exists since the insurance company by contract NEVER has to provide a payment.  This feels like fraud or at the least misleading purchasers of insurance- its a  forced discount program at best, NOT insurance coverage.  Any help??

DMK

  • Hero Member
  • *****
  • Posts: 680
Re: Copays over contracted allowances
« Reply #1 on: February 08, 2012, 03:58:58 PM »
We run into this in California fairly regularly.  It's not that they have NO coverage, it's just that the allowed $ amount for the allowed service (chiro adjustment only) doesn't even amount to their policy's co-pay level. 

For instance:  Dr. does CMT 3-4 areas (allowed amount $22.41) and mechanical traction (allowed amount $9.17)  total for the visit is $31.58,  patient's TOTAL insurance policy has a $35.00 co-pay,  The patient will ALWAYS end up paying for their treatment.

The patient (or their employer) chose this policy, and a co-pay amount that made the premium affordable.  Not your fault!  I'll bet their MD visits only get a small portion above the $40 paid.

We have more and more patients with really high deductibles ($5000.00 and starting to see $10,000.00).  They will more than likely NEVER have a claim paid by the insurance company.

You are absolutely right that it's more a forced discount program.  I often tell patients that their Blue Cross card is only a discount card!  It stinks, and it's not likely to change any time soon.

2012billingrep

  • Newbie
  • *
  • Posts: 23
Re: Copays over contracted allowances
« Reply #2 on: March 08, 2012, 09:35:45 AM »
In this case, would you then not charge the patient more than the provider's contractually agreed amount? Ie if provider's contracted amount with the insurance company is a max of $30 and patient's copay is $40, is the patient only supposed to pay $30? I assume that when they receive their EOB, it would state that the allowed amount for services is $30 and their responsibility is $30 and insurance payment is $0.

DMK

  • Hero Member
  • *****
  • Posts: 680
Re: Copays over contracted allowances
« Reply #3 on: March 08, 2012, 10:16:54 AM »
If the provider is contracted with the insurance company, they CAN NOT charge the patient more than the allowed amount. PERIOD. 

In response to your example, If the allowed amount is $30.00, even if the patient's co pay is $40.00, you can only charge them $30.00.

PMRNC

  • Hero Member
  • *****
  • Posts: 4237
    • One Stop Resources & Networking for Medical Billers
Re: Copays over contracted allowances
« Reply #4 on: March 11, 2012, 09:22:43 AM »
IF and When Obamacare takes full effect you will see this more and more, see they think forcing us to buy insurance just means all will be great..but what they don't realize is that carriers will raise their premiums forcing those that have to buy insurance to chose the higher deductible/copay plans.   But no fear.. Some states have already repealed this and won and that's good news, plus the guy that calls himself president's days are numbered.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

DMK

  • Hero Member
  • *****
  • Posts: 680
Re: Copays over contracted allowances
« Reply #5 on: March 12, 2012, 10:06:48 AM »
From your lips to God's ears!

PMRNC

  • Hero Member
  • *****
  • Posts: 4237
    • One Stop Resources & Networking for Medical Billers
Re: Copays over contracted allowances
« Reply #6 on: March 12, 2012, 03:51:39 PM »
Quote
From your lips to God's ears!

I'm not even religious but I am singing.. AMEN!
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

dmaney

  • Newbie
  • *
  • Posts: 12
Re: Copays over contracted allowances
« Reply #7 on: May 02, 2012, 01:00:52 PM »
I thought that the co-pay is the contractually allocated amount that the participant pays for the visit... and that the reimbursement takes into account the already-paid co-pay.  For example, the co-pay is $30.  BC/BS  says that the allowable reimbursement for the visit is $20 (which is not paid because the deductible has not been met).  I didn't think you were supposed to take the $20 from the already- paid $30; the $20 is the amount due over and above the $30.  So the chiropractor is reimbursed $50 total.

DMK

  • Hero Member
  • *****
  • Posts: 680
Re: Copays over contracted allowances
« Reply #8 on: May 02, 2012, 02:00:11 PM »
If the allowed amount is less than the policy's co-pay per visit you can only make the patient pay the ALLOWED amount, they are not responsible for any more than that (if you're a contracted provider).

Example: Blue Cross allows $22.41 for a 98940, the patient's co-pay on their policy is $25.00.  The EOB will show that the patient is only responsible for $22.41.   If they had a 98940 ($22.41) and a therapy ($9.17), the total allowed will be $31.58, the patient is responsible for their total $25.00 co-pay, insurance will pay the remaining $6.58. 

Regardless of WHAT their co-pay is on their policy, if the allowed amount is less, they are only responsible for the lesser amount.

If deductible is in place, the co-pay won't even kick in until the deductible is met.  They will owe for the total allowed amount for the visit .

Michele

  • Global Moderator
  • Hero Member
  • *****
  • Posts: 4743
    • Solutions Medical Billing
Re: Copays over contracted allowances
« Reply #9 on: May 03, 2012, 06:43:37 AM »
DMK described it perfectly.  The allowed amount INCLUDES the copay, and if the allowed amount is LESS THAN the copay they only owe the allowed amount.  It is not the allowed amount PLUS a copay.
Sign Up for our FREE Medical Billing Newsletter
Get a 10% discount on Medical Billing Products by using Coupon Code: 10OFF
http://www.solutions-medical-billing.com