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Copays over contracted allowances

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BH7743SS:
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:
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:
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:
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:
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.

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