Wiki When is a copay not a copay?

[SherryMoss]

This may be slightly off-topic...

Here's the scenario:

Pt has a $40 copay.
Bill 99213 for $60
EOB shows allowable of $38 and pays zero (copay exceeds allowable)

Do you post an adjustment for $20 or $22?

I have my views, but can't find anything in writing to support either answer.

 

[jek521]

When in doubt, look to the "pt owes _____ " section on the eob and adjust accordingly.

Our network contracts (somewhere in the fine print) state that we cannot bill the patient in excess of the fee schedule. If the contracted amt is $38, iit doesn't matter what the pt's copay is.

Jen

 

[halebill]

jek521 is correct. In this case, the patient should be left with a $2.00 credit.

 

[ARCPC9491]

holy moley, $38 allowable for 99213? what a rip off! knowing the copay exceeds....insurances, i tell ya!

 

[halebill]

Yeah, really should check you fee schedule on that, come to think of it. $38 is way low.

 

[ARCPC9491]

Yes, definitely ... off the top of my head our 99213 charges are AT LEAST $95 ....... I just checked the Medicare allowable for my region (Virginia) and it is $59.37 ... and not too many payers pay less than Medicare (Medicaid definitely does, Tricare occassionally) most of my fee schedules are 200% of the Medicare allowable and that pretty much covers all the allowables across the board. Some fee schedules are lower or higher of course it just depends on the negotiated rates/specialty and other factors. Occasionally we'll get a payer pay the exact charge, but then we just re-evaluate the fee altogether and have them reprocess the claim

 

[Dharmatej]

Hi Guys,

I wanted one information regarding the billing, does the patients call up your office to ask about their appointments, and their details.

 

[SherryMoss]

The dollar amounts were strictly for "example" purposes. My question was basically:

If the pateint has a set copay, should they be left with a credit balance if the allowable for the service is less than the copay?