Wiki Including Co-Payment on Claim forms

Create Wiki
N

nilsafer

New
Messages
9
Location
Ave Maria, FL
Best answers
0
Hello! Silly and basic question - what are the repercussions of not including patient payments along with claims submittals? Does this fall under Anti-Kickback?

I know it is a requirement to advise payers of such payments and if not included on orginial claim, a corrected claim should be resubmitted.
 
It definitely has nothing to do with the Anti-Kickback statutes - if anything, it might fall under the False Claims Act. However, if it does not affect payment and is not done with intent to defraud the payer by the omission of information, I can't imagine that there would ever be any negative repercussions to this. I don't think anyone is going to prosecute a payer for making an incorrect entry on a claim form that has no material effect on payment or reporting of services rendered.

I have worked in claims processing and payment auditing for a number of payers over the years and have never seen any that made use of this information. It does not affect the payer's payment determination in any way, and I imagine many payers don't even import that information into their claims system. Payers calculate patient share based on the terms of the plan - whether or not the provider has already collected this amount or not from the patient will not make any difference. In my experience, reporting the amount collected from the patient is informational only.
 
Last edited:
Thanks!!! That helps, a client of mine has few claims in which copays were not indicated on the claim but the payer deducted the amount automatically. Other payers did not, so it is a concern. I could always advise payers?
 
nilsafer said:
Thanks!!! That helps, a client of mine has few claims in which copays were not indicated on the claim but the payer deducted the amount automatically. Other payers did not, so it is a concern. I could always advise payers?
Click to expand...

The payer tells the provider what the copay will be. Not the other way around.

If the payer didn't apply a copay on an EOB, it means the patient didn't owe a copay for that service.
 
sls314 said:
The payer tells the provider what the copay will be. Not the other way around.

If the payer didn't apply a copay on an EOB, it means the patient didn't owe a copay for that service.
Click to expand...
Then a reimbursement would naturally be issued to patient if thats the case.

But when verifying benefits, the payer typically advises of any copay's, deductibles or co-insurances the patient needs to pay towards; so we collect based on that verification (which I always obtain written documentation of that and uploas to charts as back-up). Hence the reason when moneys are collected based on this information, one would need to indicate it on the claim form. Since working with this client, that is what I have been doing to avoid any issues - with the exception of Medicaid of course since we do not collect for those members.

I hope I am correct in this process! 🤔
 
nilsafer said:
Then a reimbursement would naturally be issued to patient if thats the case.

But when verifying benefits, the payer typically advises of any copay's, deductibles or co-insurances the patient needs to pay towards; so we collect based on that verification (which I always obtain written documentation of that and uploas to charts as back-up). Hence the reason when moneys are collected based on this information, one would need to indicate it on the claim form. Since working with this client, that is what I have been doing to avoid any issues - with the exception of Medicaid of course since we do not collect for those members.

I hope I am correct in this process! 🤔
Click to expand...
Your process is correct but I'd stress again that what you report on the claim form is not going to change what the payer does with the claim. If you happen to report an incorrect amount that isn't what your provider actually collected, the payer is still going to make their own determination, and you can take that information as correct. I don't think you need to file corrected claims or contact the payer to see if there was a mistake made - this would be a wasted effort. You can try a few claims just to see but I think you'll find that the payer isn't going to change anything. Just take their payment determination at face value.
 
In over twenty years I have never entered anything other than zero in that box. Claims are filed in whole amounts with the charge or charges billed. The payer processes the claim according to the provider contract, patient benefits, etc. When you get the ERA or EOB back you post the payments, adjustments, patient due amounts, etc. You should have collected the patient's co-pay, coinsurance, deductible, etc. at the time of service (with exceptions.) In a perfect world the patient's account would have had those payments applied, the claim comes back processed correctly, and it all "evens" out once you do ERA posting. You would never file a corrected claim only to update or correct box 29.

If a practice or provider wants to follow a different internal procedure and show patient payments at the time of service on the claim, I guess they could but it doesn't make sense to me. Depending on the billing system and clearinghouse it may make things confusing and/or incorrect. If a payer contract or payer dictates that the patient payment must be indicated on the claim (never seen this personally) you would have to I guess, but that also doesn't make sense. Like Thomas said, it doesn't impact how they are going to process a claim.

There are exceptions, see here if you are (which is a bad plan imo) collecting from Medicare patients up front:
https://medicare.fcso.com/claim_submission_guidelines/140841.asp

This could be a different discussion when talking about secondary and tertiary claims and not patient payments.
 
You must log in or register to reply here.
Top