Copays Pay the Bills–Honest, They Do

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.

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.

Comments

  1. KJones says:

    Doctors do not (cannot!) guarantee their patients will be “healed up at every visit”… I would never expect to skip paying because I had to go back. I wonder if that same person would be OK with having part of a paycheck withheld because work wasn’t done “right” the first time?

    • Ha! Great analogy KJones! I was racking my brain for one!

    • Nina says:

      Actually that’s a terrible analogy. First off, the doctor would not NOT get their paycheck if a second copay is not paid. And in MANY other professions, if a person is not “satisfied” or something is misdiagnosed, say, for example, in appliance repair, the repairmen comes back free of charge. I can’t tell you how many times food was sent back (in a high end restaurant I worked at, coincidentally in a medical district) because the patron was unsatisfied. My paycheck wasn’t cut, nor was the chefs. They probably did have a discussion with management about what went wrong, I imagine. Does this happen in the medical field, I wonder? In my case of misdiagnoses resulting in a second copay, the trouble was my Drs incompetence. I went to the er with a cat bite to the palm of my hand. 5 years prior I had the same thing (I neuter ferals) and it turned into a painful cellulitis where my hand was locked in as claw position and even a light the slightest touch was unbearable. So, as soon as I got bit, I tried to clean and flush the wound but within 30 minutes I could already feel the telltale symptoms. I went to the hospital right away (this was Saturday night, btw) and said I suspected I had cellulitis and that I had experienced it before and it felt the same. Well, he shook his head and kind of laUghed and said, “you don’t have cellulitis”. In my opinion, he seemed annoyed that a mere mortal would dare diagnose herself and secondly, I stated that the pain was an 7 or 8 out of 10 by that time ( throbbing, unbearable) and that the Tylenol wasn’t even taking the edge off. I have a lot of tattoos. He said it shouldn’t hurt that bad and to alternate blah and blah. Got the feeling he thought I was drug seeking. So he sent me home. I ended up going back in w/in 8 hrs in excruciating pain- I had my child drug and epidural free, so I’m no baby-and a different dr confirmed it. My first experience 5 yrs ago, I was given oral antibiotics, pain meds and sent home. I was fine the next day. This time, because of the delay, I was hospitalized on iv antibiotics and a haNd surgeon was brought in b/c they were concerned it might have spread causing permanent damage. I had to pay my copay both times. I have another similar situation of going back after a misdiagnoses that could have been avoided haD the dr listened to me. My point is that this isn’t just patients expecting Drs to be perfect and always get it right but more so about Drs believing they are always right and perhaps factoring in expenses, biases or whatever else instead of the patients best care. And Drs in the US make too much money. Seriously.

  2. Sandra Kowalski says:

    Hi Christine -I was just in the new office the other day- Beautiful BTW – but I never saw a “Guaranteed to make you better on the first try” Sign! I think it is wonderful that Doctors like your group, know and help some needy patients. But why do patients feel they deserve NOT to pay a co-pay? I will never understand that. The only time I ever refused to pay was whenduring a routine cleaning my Former dentist had a dental assistant put “filler” over what she thought was a chipped tooth but turned out to be decay. Needless to say It got so bad I had to have root canal and a Crown. To make matter worse, it took 4 tries with crowns before they finally got one that fit right and they didn’t break. I then got a bill for root canal and 4 crowns for over $6K. I call the office and told the billing person I only came in for a cleaning and then waited on the phone while she spoke with the dentisit. After 10 minutes the person got back on the phone and said the dentist said to ignore the bill as it was a mistake – He forgot to mention who’s mistake it was. Needless to say I immeditaley changed dentist!

  3. Barb Lesky says:

    Well put Christine! This copayment is part of the patient’s contract with their insurance. I for one am grateful for the physicians that participate with my contracted insurance.

  4. Diane says:

    I would love to have a copay again, would be happy to pay it twice if I did not get better the first time. With a $4000 deductible and monthly insurance also up over $100 a month to $650 per person, can’t afford to even go to the Dr the first time. if people have to pay for the visit, maybe the follow up visit if they did not get better the first time could be less than the first visit, or handled by phone? Cheaper to not have insurance at this point.

  5. Thomas Tober says:

    Hi Doc,
    Michele and I love your Blogs. Keep em coming! Your practice is the best all of the Docs care about how your are doing 110%.

  6. A says:

    As both a patient and a Benefits professional, I hear what you are saying. And I think that your patient is incorrect in assuming that a doctor can guarantee that one visit will cure what ails you.

    However, what I get very frustrated by (I have not experienced this at your practice) is the need to come into the office for a visit only to have to be told that I have to:

    1) get lab work done;
    2) get a scan done
    3) visit another practitioner;

    and then return to the practice resulting in 2 co-payments for the same issue.

    While it is understandable that this will sometimes happen, other times having a conversation with the doctor can eliminate this. In your practice – the availability of connecting by phone and by email is great and can eliminate this issue completely – but I have seen it happen elsewhere and it is very frustrating.

    Also, (I’m sure you know this) but research has shown that when a doctor says “I’m sorry” that patients forgive easily. And sometimes doctors get it wrong. Saying I’m sorry we didn’t get this diagnosis right or I’m sorry we weren’t able to fix this the first time can be worth its weight in co-pay.

    In the end, medicine is a business an art and a science, we all expect to get paid for the work we do, I don’t see any reason it would be different for a doctor.

    • Great points Andrea. One of the problems is that doctors are still not able to bill for phone or email time. For me, 30 minutes on the phone is equal to two patients seen in the office. As busy as my practice is, I end up on the phone from my driveway so the kids don’t see me or on email at midnight. Time is time. Bringing people into the office for these consultations ensures 1. proper time in the proper setting (quiet office not noisy driveway) and fair reimbursement for time spent. Obviously I am not talking about a two minute email or simple question rather long complex conversations.
      Thanks so much for your insight.

  7. Karen Baker says:

    I spent the better part of this morning making payment plans for the $7k In copays that I’ve accrued this year in medical expenses. While it is depressing to see this money leave my pocket, not once did I think that these medical professionals didn’t deserve their payment. Without great doctors like yourself, I would definitely lose my battle with cancer. Hard to put a dollar amount on my health.

  8. Donna says:

    Fees are not always explained well. I had a bunion removed and all the followup visits within 3 months were free. I can understand why someone thinks if it is the same issue then you already collected a history, are familiar with the circumstances and do not have to spend as much time treating the patient. Insurance companies do not explain benefits well in the summary charts and who can read the whole 200 page booklet. Unfortunately the doctor is left with explaining this to patients. I understand both sides of this one.

    • That is precisely the problem Donna. People don’t understand their own benefits. Sometimes there is a feeling that if “you have insurance” everything should just be covered by that…not so.

    • Kellyann says:

      I understand the frustration. I feel every time my kids are sick it takes 2 visits. Since we have a High Deductible Health Plan that is expensive! Also, I know that the costs when I’m picking my benefits and know I will have to.pay more at the doctor if I chose lower premiums. Donna, since your bunion was a procedure, it was most likely billed as a case rate. Which includes the follow up. Doctor gets paid the same if it took 4 hours or 8 hours.

  9. Susan Higgins says:

    I am not a patient…..but love reading what you have to say. (I started following you on FB when one of my friends reposted one of your blog entries) You are always so candid and right on spot. I appreciate your “up front” opinions. I am ready to find a new physician and after following you for a few months….I think I found my new doctor! (If you’ll have me?)…

  10. Donna says:

    I should clarify I understand why patients can be confused. But I think you should pay for every visit particularly because the office does a lot of work you do not charge for.

  11. Capertillar says:

    If you take your car to the autobody shop for X problem. The autobody shop fixes X problem, and you go home. 2 days later, X problem recurs, and you take it into the autobody shop for a 2nd visit to fix X problem, again. Do you pay a second time?

    If you go in and have someone do your taxes, and there’s something wrong with the taxes, it’s incomplete or whatever, and you have to go in again, do you pay a second time?

    If you go in to see your doctor, and s/he prescribes medication, and you do not get better, and you have to go back in again just to get different medication prescribed… should you pay again?

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