Wiki Keeping co-pay after payer denies for timely filing

[MnTwins29]

Hi - I have been asked if the organization/provider can keep the co-payment made by patients when a claim is denied for timely filing. This was asked for it being applied to the insurance allowance and writing off the rest? I don't think this would be allowed - if denied, there would not be any "insurance allowance" - but is this a regulation, an internal policy by each organization or something in the payer contracts?

Thank you.

 

[csperoni]

I would go by the payor's EOB. If the EOB lists no patient responsibility, then the patient should be refunded. It is likely part of your payor contract.

 

[CBLENNIE]

I would go by the payor's EOB. If the EOB lists no patient responsibility, then the patient should be refunded. It is likely part of your payor contract.

I work for a payer, and I agree with Christine, we would expect our contracted providers to only bill the patient based on what the EOB/remit shows as patient liability. So, if you submitted the claim to the payer and it is denied as past timely filing, assuming that the patient didn't cause you to file the claim untimely, then you can only keep any copayments that the EOB/remit shows the patient owes per our provider contracts.

If the patient did something to cause you to file the claim untimely, like not giving you their insurance information or providing incorrect insurance information, the patient should not be liable for the copay, and you should refund the copay the patient previously paid. If the patient did cause the claim to be filed untimely, you need to submit an appeal to the payer with the proof so that the claim can be reprocessed to show as patient responsibility.