Wiki Question on collecting/refunding copays

[lbristol]

I hope someone can help me with this....our front office collects copays for office visits that are not annual routine exams. Sometimes the insurance company will process and pay the claim at 100% w/o acknowleging the copay on the EOB. We don't mind refunding the patient for any credit balances, however, I'm afraid the insurance company may come back some time later and reprocess the claim leaving the patient with a balance. If we are contracted with the insurance company and we collect the copay at the time of service, are we obligated to refund it to the patient if the claim is processed incorrectly? what is the correct way to handle this? Thanks!

 

[dclark7]

Probably the best way to handle this would be to call the insurance comapny and find out why it was processed without a co-pay. Some patients have an out of pocket maximum and if they met this they would not have to pay anymore. It seems to me it would be easier to call the insurance company to get an explanation rather than refund the pateint and have the claim recouped because an error was made.

 

[lbristol]

Thank you!

 

[swilliams2]

refund

I agree with Doreen. We call the insurance for an explanation on all claims before refunding. We have found recently more and more plans pay 100% on certain diagnosis. When we use a pre-op diagnosis some process under routine benefits and pay 100% because it is a V code. Others don't apply a copay to diabetes or mental health codes so any that start with a 3 are paying 100% (sometimes). It's good to get the info before refunding but also we note that patient's account so we don't over collect in the future when billing the same diagnosis (we collect at check-out, not check-in).
Thanks,
Stacy