Pediatric Coding Alert

Question: When a patient is asked to pay a co-pay and cannot pay now for whatever reason, are we legally bound to send a written bill, or is a copy of the superbill with the balance of the co-pay showing sufficient for the insurance companies? Is the superbill sufficient for billing documentation, or does the charge have to be documented in the computer and a physical bill sent to the patient? Is a co-pay required on a follow-up visit?

If a patient is indigent and signs a form stating he or she cannot pay the co-pay, can we write off the co-pay without billing the patient and still be in compliance with the insurance company? How long are we required to keep an outstanding patient balance on record before we can write it off? How long are we required to keep billing documentation? If a patient continuously does not pay his or her balance, can we legally refuse treatment?

Michigan Subscriber

Answer: You are confused about the details of what needs to be done. Your contracts with most insurers say it is your obligation to collect the co-pay. It is the patients obligation to pay it. Insurance companies take co-pays quite seriously, since they use co-pays to control utilization. The cost of billing co-pays generally exceeds the co-pay and therefore a firm office policy should say that co-pays will be paid at the time of the visit, and no later than 30 days after the visit, so there is not a need to bill. Patients who violate this policy may need to be dismissed from the practice.

You can also simply collect it at the next visit, rather than summarily dismissing the patient. As far as a patient not being able to pay a co-pay, for the most part, patients in HMOs are employed, as Medicaid and SCHIP do not have co-pays. If there is a legitimate reason for writing off the co-pay, that is always the pediatricians prerogative, as long as it is not done to defraud the insurer or government.

If you choose to dismiss a patient for nonpayment, be sure that you comply with both the HMOs rules for dismissal as well as the standards for dismissal in your state (e.g., letter sent registered mail with return receipt, coverage for emergencies for a reasonable period of time until a new pediatrician can be acquired, forwarding records to the new pediatrician after you have received a written release from the patient) so that you cannot be accused of abandonment. Also, before discharging the patient, you should report the patient to the insurance plan. Report the patient when two co-pays are missed. The health plan will usually follow up directly with the subscriber.