Forum - Questions & Answers

Aug 3rd, 2014 - sigma327

Copay and insurance payments.

I bill for a dermatologist and i'm very new and was hoping for some help in collecting copays. usually our practice is to collect copays upfront at time of service, we collect them copays for each office visit upon verifying benefits. But when we submit the claim we receive the EOB without a copay on it including a full payment based on the allowable of the service which then leaves me with a possible refund to the patient? is this normal, what can be done to avoid it. Do we stop collecting upfront or do we reprocess all our claims in order to have a copay applied and listed on the EOB.

Thanks.
Amy.

Aug 3rd, 2014 - Kat31477 56 

re: Copay and insurance payments.

Copays are plan specific and each plan is different. You're going to owe the patient a refund in these cases. I would revisit how you are verifying benefits, perhaps the person looking at the benefit verification is interpreting it incorrectly. Note the accounts where no copay is required to avoid future over-collection from the same patients. There's nothing you can do to avoid it, per se, other than try to be more accurate when verifying benefits (contact the plan and ask if there is a copay for your specialty, etc).

Aug 3rd, 2014 - Ray1954 1 

re: Copay and insurance payments.

We have been finding that when the EOB is received, some insurances are actually requiring only a percentage of the listed co-payment amount depending on the level of service that has been billed, which almost makes it impossible to know what to ask of the patient prior to the office visit.

Aug 4th, 2014 - Kat31477 56 

re: Copay and insurance payments.

Collect what you think is right up front. Adjust accordingly after first visit processes with the insurance - either refund the patient, or use partial credit towards subsequent visits. After the first visit, you should be able to accurately determine what the patient responsibility will be based on prior claim processing. Recheck benefits if patient is absent from treatment for 6 months, changes insurance plans, or at the beginning of the year (because plans may change their benefit levels).

Aug 4th, 2014 - shanbull 51 

re: Copay and insurance payments.

[Collect what you think is right up front. Adjust accordingly after first visit processes with the insurance - either refund the patient, or use partial credit towards subsequent visits. After the first visit, you should be able to accurately determine what the patient responsibility will be based on prior claim processing. Recheck benefits if patient is absent from treatment for 6 months, changes insurance plans, or at the beginning of the year (because plans may change their benefit levels). ]

Yes this is exactly how we do it also, if there was an EOB with a lower copay than what was paid, we give the patient a choice between a refund or applying the credit toward another appointment. Usually they choose the credit toward another appointment.

Aug 28th, 2014 - vsmichael 20 

re: Copay and insurance payments.

Also, if a patient has reached their maximum out of pocket with their plan, they typically don't have to make a co-payment. Insurance pays at 100% of the allowable.



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