This is one of those topics I expect to get some heat for but here goes.
Not long ago, I heard about a patient who had come to the office for a sick visit. She paid her copay of $15. Later in the week, she appeared to be getting worse and was asked to come back. She saw the doctor and got treatment. She did not pay another copay. Her reasoning? “She should have made me better the first time.”
Here is how a copay works.
Your insurance determines what they consider an “allowable charge” for an office visit. Then, based on the plan you or your employer chooses, your copay is determined. A less expensive plan will likely have higher copays. While a plan that costs more in premiums will have less out of pocket costs.
Come time to square up, we submit the bill to your insurance. They say that our “allowed” fee is $50. Your copay is $15. Therefore they pay $35.
If your copay is $45, your insurance would pay $5 for that same visit.
In the case of HMOs (not evil nasty things –in fact every practice needs some percentage of HMO patients,) we receive a monthly per patient amount. That amount is paid to us whether the patient is seen zero times that month or fifty. The only thing that we get for that visit is the patient’s copay.
This monthly per patient fee varies but for a young and healthy patient can be less than $10.00. An older, more complicated patient will have a monthly amount that is a bit higher.
While we would love to write off copays in many situations, legally, we cannot.
What few people outside of the industry realize is that if we bill an insurance company but fail to “make a reasonable attempt” to collect a patient’s copay, we are committing fraud.
In the above scenario, the only answer is to see the patient absolutely for nothing–no insurance bill, no copay.
Medical practice is a business. We cannot possibly stay afloat, provide good quality care, and offer all aspects of service patients need if we repeatedly write off copays–especially if it means not billing the insurance either.
Most doctors would agree that we will bend over backwards for a struggling patient or family. I will reimburse patients if they have experienced an unreasonable wait, have a bad interaction with an employee or have to return to the office because something was forgotten (vaccine, lab draw etc.)
But to remain on the non-fraudulent side of the law, I must provide my service for ZERO dollars.
What business could consistently do that and not go under?
No doctor I know, refer to, or interact with is making his living drumming up repeat office visits and repeat copays.
If the first visit did not result in an improved condition, doctors need to reevaluate the patient. That second visit will take the doctor’s time and resources. The electricity will need to be on and the staff will need to be paid.
Let’s have an open, constructive discussion. I know many docs, insurance brokers, and certainly patients are reading this. I would love to hear those different perspectives.
Have you been annoyed at having to pay a second copay? Or, has your doctor made it a point to forgo your copay in certain situations? Please do not name doctors in your responses, let’s just use this for informational purposes.