# Patient's Refusal to Pay Cost-Share



## bmcginnis (Jul 16, 2018)

Looking for some guidance. In my 7 years in this practice, I have never had a patient refuse to pay an invoice. We've never had to use a collection agency. Patient was billed timely for cost-share of $330.

Patient's response to my invoice is that copays should be $12 per visit and not $30. My response: According to insurance company, cost-share was increased 1/1/18 he should have received documentation with his plan updates. Invoice remains due to us. 

His response: our staff did not notify him of any copay and there are no visible signs about copayments. Whether or not he pays the invoice is his choice. Our office staff mentioned to him at the first visit that he'd be billed for any balance due. My response: while I understand your frustration, it is ultimately the patient's responsibility to know, understand and abide by the terms of their plans, including but not limited to what services are subject to cost-share or copayment. We were willing to set up a payment plan if needed. If no response, we would seek alternative arrangements for collections.

Patient's response received today along with a check for $30 for payment in full. His letter states that our billing practices are very misleading and at no time was there mention of a copay either before or after each visit and that we took it upon ourselves to consolidate all these so-called co-payments into one. All of the visits were paid on the same remittance. 

I'm looking for guidance as to any specific language I should include in my final letter to the patient. I am already including this: While I am pleased with your attempt to make payment, I am unable to accept it. The money order shows an amount of $30.00 as payment in full for services rendered 01/22/18 through 03/26/2018. In fact, the total amount due is $330.00. We are not willing to accept $30 as payment in full.

Thanks in advance for any comments.

Billie Jean
New York


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## coding4fun (Jul 17, 2018)

*Co-pay*

Do you mind elaborating what the service was which was rendered to the patient?  I do believe that the bottom line would be that "it is a courtesy that we file your insurance for you".  We too have some patients who want to debate their bill and the fact that their ins carrier applied to a deductible or just did not pay for whatever reason.  I am sure that you have investigated the reason for the denial so that you can address within your letter.  I really hate to mention that if your bill remains unpaid our office has a policy that all accounts with more than 90 days past due will be considered for collection referral.   Good luck with your letter and I hope that the patient sees the light and pays his bill.


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## pegsmith (Jul 17, 2018)

*pt cost share*

I would contact his insurance company,explain the problem and ask them to call the patient. I have done this before and it worked quite well. 

Peg Smith CPC


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## jorellana42 (Jul 18, 2018)

I'm sorry this is so frustrating for you.  We come across this all time time, as our patients think we are a "free clinic".  As an FQHC, we are forbidden from reporting any patient balances to a collection agency because our mission is to care for patients regardless of their ability to pay.

This being said, the patient enters into a contract with their insurance carrier, just like our providers do.  In the contract it should state that the patient agrees to pay any out of pocket costs, as illustrated in their specific plan (copays/coinsurance/deductible).  I would read over the payer contract that you have with the particular carrier to see if there is language regarding patient financial responsibility.  You can use this in your defense.

Good luck!


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## JCaillouet (Jul 19, 2018)

bmcginnis said:


> Looking for some guidance. In my 7 years in this practice, I have never had a patient refuse to pay an invoice. We've never had to use a collection agency. Patient was billed timely for cost-share of $330.
> 
> Patient's response to my invoice is that copays should be $12 per visit and not $30. My response: According to insurance company, cost-share was increased 1/1/18 he should have received documentation with his plan updates. Invoice remains due to us.
> 
> ...




One thing concerned me: 

1) 





> _our staff did not notify him of any copay and there are no visible signs about copayments_



Just because I'm stubborn in this regard, am currently working Financial Counseling and have worked Front Office, are signs out front visible that patient is responsible for their share at time of service? Are Clinical and Front Office Staff aware that if a chart is flagged with copay or balance due to 'notify' financial counseling? (I've had clinical staff at one office 'escort' patient past Financial Counseling till the Office Manager had to step in..)

With that being said: 

Along the lines of: _As per the terms and provisions of the contract with your insurance company, any amount that the company has deemed as 'patient liability' which includes Cost Share, Copay, Coinsurance and Deductibles, are ultimately your responsibility. We encourage you to reach out to your insurance company to resolve any disputes. It is our policy that accounts 90 days past due are referred to a collection agency and if we do not hear from you within thirty days from the date on this letter we will assume you do not dispute the bill and will respond accordingly. _

G'luck


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