Gastroenterology Coding Alert

Collecting copays may be straightforward, but delving into deductibles and Medicare coinsurance amounts can be trickier. In fact, many practices believe it's inappropriate to collect coinsurance payments from patients while they're at your office since you must first wait for a remittance advice to arrive - however, that's not the case. Read on for tips that can help you collect these dollars.

Coinsurance:  If you properly verify the patient's coverage up-front, you can collect Medicare coinsurance payments before patients leave your office.

• Advantage: For defined contribution amounts (which many Medicare Advantage programs and private payers offer), you can collect coinsurance when the patient checks in at your practice, since these figures don't depend on which services you render. Some electronic subscription services allow you to verify the patient's coinsurance amount and whether their deductible has been met before the patient arrives for his visit. Therefore, when you make the patient reminder call, tell them approximately how much they'll owe you in coinsurance or deductible amounts.
• Part B MACs: When dealing with Part B, you can typically charge the patient after their service but before they leave your practice. When you see the patient at checkout, read the chart to determine what services the physician performed, then collect the appropriate coinsurance before the patient leaves the practice.

The Difference with Deductibles

The rules for deductibles may be slightly different, depending on the insurer. From a compliance standpoint, if the practice knew without a doubt that the patient's deductible had not been met, there is nothing that prohibits the practice from collecting it at the time of service prior to sending the claim to Medicare.

However, this may not necessarily be a good business practice. Secondary payers will usually pay you the cost of the patient's deductible, and the secondary payment often arrives at your office before you even receive your Part B reimbursement, so patients with secondary insurance typically won't have to pay you deductible amounts.

Some practices collect the deductible up-front as a rule, especially if they see the patient early in January, and then figure they'll just issue a refund later if necessary. But generating all of those refunds can be a headache when February rolls around.

Not to mention costly: What you collect from the patient up-front probably isn't as much as you'd spend processing a refund, so most coding experts recommend that you simply wait the two weeks (on average) that it takes to get your Medicare payment information and then determine whether the patient owes anything on the deductible.

Even if you can predict what the Medicare EOB will say (which is nearly impossible), the odds of knowing whether the patient will owe you his deductible get worse and worse every day after January 1, and that's before you start to factor in the implications of the patient having a Medigap policy you weren't aware of that would have picked up the deductible for the patient in the first place.

Example: Suppose you see a patient on January 15. She was referred by her primary care physician for chronic diarrhea, but she saw the PCP at the end of December. She tells you that she hasn't seen any other physicians yet during the year. She also mentions during the history portion of the E/M visit that she performs her glucose test daily and that she just received a new box of glucometer strips the day before, so she is prepared to continue testing her blood sugar.

Reality: Although this patient has not seen a Medicare physician, she probably did pay some money toward her deductible when she ordered the glucometer strips.

Bottom line: Determine whether collecting that deductible is really worth your while from a business standpoint before you ask the patient to pay it at the time of service.

In black and white: Although Medicare doesn't prohibit you from collecting coinsurance or deductibles at the visit, some of the MACs discourage you from collecting the deductible. Part B MAC First Coast Service Options says in an FAQ document on its website (which was updated on Aug. 15, 2017), "If you believe you can accurately predict the coinsurance 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 over-collection is considered program abuse and can cause a portion of the provider's check to be issued to beneficiaries on assigned claims."

What about for procedures? Generally, unless a facility fee "deposit" is within your responsibilities when the practice owns the facility, trying to collect a copay or deductible for endoscopic procedures is unwise. After all, most screening exams will have no copay or deductible; and generally, it isn't known before the procedure whether biopsy, polypectomy, or other therapeutic services will be performed.