Large Deductibles and Co Pay Tips

Large Deductibles can be resolved in a couple ways

In our business we get asked how to deal with a client that has a large deductible.  Our responses are listed below.

  • Client can waive usage of their insurance
  • The provider may charge the client and expect to be paid the allowable or some portion of that until the deductible is satisfied.
  • If under contract with the insurance company it states that you may not charge the client more than the allowable not that you have to collect it.
  • If in a group the client can be assigned to a non contracted provider with that insurance.  Then the client may be put on a  sliding fee.
  • If out of network with the insurance the client may be charged the standard fee and the client may go elsewhere or decide to pay for that service in full.

Co Pays

With a lot of non profit agencies they struggle with how to work with co pays when the client states that they cannot afford to pay 60.00 per session.  If this is an in network provider than the contract says the client must be  charged the co pay.  It does not say that the client must pay the co pay.   So keeping this in mind what we often advise our groups is that which is stated above.  The client must be charged the co pay, a negotiation may be made with the client to accept a lesser fee and write off the difference.  The client ledger must show the 60.00 charge but it is not necessary to show a payment of 60.00.

Words of Caution

Always keep in mind that often the allowable for a service may only be 60 or 65 so that co pay may be the only reimbursement.   There are a number of Aetna policies out there with a 70.00 co pay.  Master’s level providers allowable is almost always less than that.  So the best bet may in some cases be not to use the insurance but to negotiate with the client for a reasonable fee.   Be mindful of the allowable whether  in network or out of network when co pays or deductibles are involved to ensure that you get the reimbursement you deserve for the clients you serve.

**Medicare deductible is a different animal and it is only 183.00 for Part B.  The advice is not to charge the client the deductible and wait for the explanation of benefits to come back before pursuing this with your client because they may have a secondary that picks it up.

 

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