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Pediatric Coding Alert

Co-Pay or No Co-Pay? That Is the Question

Published on Wed Feb 11, 2004

Collect required co-pays - even if it feels wrong

When an established patient reports to the pediatrician's office for a level-one evaluation and management service (CPT 99211 , Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician), most insurance carriers mandate that a co-pay be collected from the patient's parents.

Since 99211 is a low-level service and the pediatrician isn't usually present when it's performed, some practices feel uncomfortable charging the co-pay. Experts warn against waiving any required co-pay collection, however. Insurance companies aren't concerned with whether you feel you've earned the fee or not; they expect a co-pay to be charged on almost every E/M service.

"If your contract with the carrier states that you have to charge an X-dollar co-pay for every E/M visit, you have to charge it, or you're in violation of your contract," says Jeffrey Linzer Sr., MD, FAAP, assistant professor of pediatrics at Emory University. 

According to Peter Rappo, MD, FAAP, a practicing pediatrician and assistant clinical professor of pediatrics at Harvard University School of Medicine, many pediatricians have forgotten the true purpose of co-pays: decreasing the abuse of certain codes.

"The assumption about practices that attempt to waive co-pays is that they are trying to get people in the (practice) door," he says. "Insurance companies build that assumption into their payment structure, because they know if they set the co-pay at a certain level, it will decrease utilization."

If you don't collect required co-pays, you are interfering with the carrier's cost controls, something Rappo says most insurance companies do not look kindly on.

"The theory behind co-pays is not that (insurance companies) want to deny care to people who really need it, but they want to come up with a strategy that will decrease the use of 99211 among the population that doesn't really need it," Rappo says.

Worried about explaining the necessity of the co-pay to parents? Here is a solution: Tell them that the co-pays are based on the patient's presence in the office, not the cost of the service. Make sure the parents understand that whether an expensive procedure or a minor one is performed, the co-pay is the same as determined by the insurance plan.

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