Reader Question: Limit on Copayment

Question: Is there a limit on what the patient has to pay? For example, when we run a procedure through our APC grouper, it gives us the total amount of the procedure, what HFCA will pay, and the copayment that the patient is responsible for. In many cases, what the patient pays is higher than what HFCA will pay. Is the patient responsible for that whole copay sum, or just up to a certain percentage of it?

Beth Hearn, CPC
Hillcrest Hospital, S.C.

Answer: Copayments under APCs are sometimes higher than what Medicare will pay. As time goes on and the APC weights and conversion factor are adjusted, the coinsurance will represent a lower percentage of the total payment for the procedure, and will eventually be frozen at 20 percent. In the 2001 Outpatient Prospective Payment System (OPPS) Interim Final Rule, HCFA clarifies that any reduction in coinsurance that occurs in applying the (inpatient deductible) limitation will be paid to hospitals as additional program payments.

The 2001 inpatient deductible has been set at $792 per visit (transmittal AB-00-98, dated Oct. 10, 2000).

Hospitals are given the opportunity to discount co-pays per the regulations. However, it is true that the co-pays are often higher than the APC payment and will remain so until the APC payments catch up over time.

- Published on 2001-01-01