Collecting Co-pays

My question is: When it is appropriate to collect a co-pay?

I know a lot of this would be insurance based. But, I have a couple of scenarios in which I'd like to know if the co-pay should have been collected.

Scenario 1:
I have a patient being seen by a nurse (RN, not NP or PA; she's not credentialed) for routine foot care. Those charges are billed under a supervising physician, not under her. Should a co-pay be charged for this service?

Scenario 2:
I have patient(s) being seen by a physician for an EMG/NCV only. These patients are almost always seen by the ordering physician on the same day to go over the results (not by the physician performing the EMG). My question is should this patient be charged a co-pay for the EMG? I want to know if they should ever be charged the co-pay for the EMG, whether they're seen for results on the same day or not.

There has been much discussion over this issue in my practice. Some coders feel that co-pays are only appropriate for E/M services, therapy, and sometimes MRI and surgery when insurance specifies. Others feel that it's always appropriate to collect a co-pay (except when the patient is in a global, unless it's an unrelated issue).

Help!

re: Collecting Co-pays

Scenario 1: Contractually speaking the copay is part of the reimbursement to your provider calculated by the insurance company, and they pay you less directly because of it, so yes it would be appropriate to collect the copay as long as the direct supervision requirement is met and the physician is still following up with the patient at regular intervals. Here is the exact wording from the Medicare manual:

"Where a physician supervises auxiliary personnel to assist him/her in rendering
services to patients and includes the charges for their services in his/her own bills, the services of such personnel are considered incident to the physician’s service if there is a physician’s service rendered to which the services of such personnel are an incidental part and there is direct supervision by the physician.
This does not mean, however, that to be considered incident to, each occasion of service by auxiliary personnel (or the furnishing of a supply) need also always be the occasion of the actual rendition of a personal professional service by the physician. Such a service or supply could be considered to be incident to when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflect his/her active participation in and management of the course of treatment. (However, the direct supervision requirement must still be met with respect to every nonphysician service.) "


Scenario 2: Same thing, it's really not about what the coders think. It's pretty cut-and-dried as far as the contractual agreements go. Your practice could get into trouble for not collecting copays the insurers assign to patients without a valid reason (either as documented financial hardship for the patient or professional courtesy to employees and colleagues). You should have a policy for what can be written off and what can't that complies with the contract requirements of the insurers. To do otherwise, or only collect on certain procedures, constitutes insurance fraud.

Per this explanation from a lawyer who specializes in health insurance contracting and compliance:

"Co-Pays are absolutely mandatory; by co-pays I am referring to amounts the healthcare provider is required to collect from the patient including co-pays, deductibles and co-insurance. While I know many of you find it burdensome, annoying and potentially detrimental to the practice (maybe patients will go elsewhere if I try to collect?) to bother patients with co-pays, deductibles and co-insurance, please allow this email to remind you that if you do not collect all of the above, you are in fact committing insurance fraud. The prior statement does not apply of course if you are strictly fee for service, no insurance participation whatsoever and do not accept assignment. The theory behind this type of insurance fraud is that the patient has executed a contract with a third party payor accepting a certain financial responsibility for their coverage (to pay their premium, deductible and co-payment)."
Source: https://www.kirschenbaumesq.com/article/collecting-co-pays-required

re: Collecting Co-pays

Thank you very much!

So, in the case of Scenario 2, where the EMG is performed by one provider and the E/M for results is another provider, would you charge two co-pays?

re: Collecting Co-pays

I would check the patient's eligibility inquiry. If there is normally a copay listed for both an office visit and diagnostic procedures I would say charge both. If it's unclear, call the insurer if there is time to clarify or just charge the one copay and wait for the remittance from the insurer to see if you need to bill the patient for the remaining copay. That way you are unlikely to accidentally overcharge the patient but still collecting at least some of the assigned copay before the patient leaves.