Co Pays Coinsurance and Deductibles

We are often asked this question about Co pays, Coinsurance and Deductibles.  We must talk on this topic at least 5-10 times a week to one customer or another.

1) Can you charge the client less than the co pay?

The answer is No you must charge the client the co pay on your ledger but what you accept is between you and the client.  If you are contracted with an insurance company the specific wording in your contract says that you may not charge your client more than the allowable or expect them to pay more than the allowable.  It does not say you cannot accept less than the allowable.  Be aware of what your allowable is for a specific service and do not shortchange yourself.  For instance many times I find that the co pay exceeds the allowable.  So your client comes to you and says I cannot afford 60 per visit so you slide it down to a more reasonable amount for this client and then the insurance comes along and applies all to the co pay and you get whatever you got from the client.  This is something I try to help our customers be aware of when we do the verification of benefits.

2) What is the fee for this client when the client has a coinsurance?

Co pays are a flat amount each service, but coinsurance is a percentage of the allowable for that service.  This amount will differ from service to service.  If you do 45 minutes or 60 minutes the coinsurance amount will change so you can’t set a flat amount for each service unless you intend to do the same service each time.   You must show on their ledger that you charged them the correct coinsurance and no more.  Again what you decide to accept as payment from your client is your business.  The accounting just needs to show that you did indeed charge them that amount.

3) How should I handle the deductible?

Here is the problem with deductibles,  other providers can meet that deductible it is not just your practice.  Be aware if your client is going to other types of providers because if I was to tell you that it will take 10 visits @60.00 per visit to meet that deductible it may take less because the client has seen another provider for a different service and it has been applied to their deductible.  Again if you are contracted with this insurance you do not want to charge the client more than the allowable until they meet that deductible.  If you are not contracted with the Insurance you may charge them your full fee.

These items tend to trip providers up a lot and we try to warn our customers against charging a customer a flat rate to meet the deductible it may be better to take a percentage of the allowed amount and advise them that once the claim has been processed by the insurance there may be a difference that they will be responsible for at a later date. Or you may choose to eat that it is entirely up to you.   Some of our customers use this method if the deductible is less than 1000.00 they will charge the client 50% each visit until deductible is met and if it is more that 1000 but less than 2500 they will charge the client 70-80% your choice until that deductible is met.  If more than 2500 then they charge the client 100%.  But of course it is your practice you can decide which way to do it.  Your billing person should advise you when the insurance starts paying and the client fee can be adjusted.

 

Medicare Deductible FAQ

Q: When is it acceptable to collect the deductible from the beneficiary?
A: When assignment is accepted, Medicare Part B recommends:
• Since it is difficult to predict when deductible/coinsurance amounts will be applicable – and over-collection is considered program abuse – do not collect these amounts until you receive Medicare Part B payment.
• If you believe you can accurately predict the coins…urance amount and wish to collect it before Medicare Part B payment is received, note the amount collected for coinsurance on your claim form. (We do not recommend that you collect the deductible prior to receiving payment from Medicare Part B because, as noted above, over-collection is considered program abuse and can cause a portion of the provider’s check to be issued to beneficiaries on assigned claims.)
•This was posted under FAQ on Medicare Part B website. The deductible for 2014 will remain the same it will continue to be 147.00. Some folks have it covered with their supplements while others do not. Also to just give you the heads up the fees will change on January 1 and I do not have the fee schedule at this time but Medicare will be paying all Mental Health Services at 80% instead of the 65% they have been paying as of January 1, 2014.