I now know that each insurance has a predetermined amount that they pay for claims, but what about co-pays? I know that Medicare specifies what the co-pay is for their claims, but are there similar guidelines for other insurances? On my insurance card it specifies how much a co-pay is for in and out of, network providers, is that what I should charge for co-pays, or is it something that I determine on my own, as is the rate I bill for the claim?
The amount that a patient has for co-pay is determined by their contract with the insurance company.
For example, when I go to get insurance, the insurance agent gives me different plans to choose from. These different plans have different monthly premiums that I must pay. Usually, the larger the premium, the lower the co-pay or deductible.
When you bill the insurance company, the insurance company will tell you how much of the bill is the patient's responsibility. The co-pay will be included in the patient's responsibility.
It is more and more common for practitioners to ask for the co-pay at the time of service. Usually, the amount of the co-pay is on the insurance card. If it is not, then you may have to call the insurance company to find out what the co-pay is. The other option is to not ask for the co-pay up front. Instead, wait until you have billed everything through insurance and then send the patient a bill for the remainder due (co-pay, deductible, etc). It is your decision on how you want to handle the co-pay (collect up front, or wait until after insurance).
If you are not in-network, then you are not restricted to only collecting a co-pay. You can attempt to collect the entire charge from your patient.
Examples:
In-Network Example: By being in network, you contracted with the insurance company not to go after the patient for more than the contracted rate for the service.
You charge $200.00 for a service. You bill this charge to the insurance company. The insurance company has a rate of $120.00 for this particular service, and the patient has a $10.00 co-pay. They respond with the following Explanation of Benefits.
Billed Adjustment Patient Responsibility Amount Paid
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$200.00 $80.00 $10.00 $110.00
Here, you received a check for $110.00 from the insurance company, they are also telling you that you need to collect $10.00 from the patient. You would then, in Therabill, make an $80.00 adjustment to the session and enter the $110 payment. The balance due on the session will then be $10.00. You create a client statement and send it to the patient.
Out of Network Example: You are not contracted to the insurance company's rate for this service. Keep in mind; how the insurance company reports this, or the exact amount they pay may differ depending on the insurance company you are submitting too. But the concept is the same.
You charge $200.00 for a service. You bill this charge to the insurance company. The insurance company has a rate of $120.00 for this particular service, and the patient has a $10.00 co-pay. They respond with the following Explanation of Benefits.
Billed Adjustment Patient Responsibility Amount Paid
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$200.00 $0.00 $90.00 $110.00
Here, you received a check for the $110.00 from the insurance company, but they are telling you that the patient owes the rest. NOTE: The insurance company still took out the co-pay on what they paid (they didn't pay the 120.00, they subtracted out the $10.00). You would then enter the $110.00 payment into Therabill. You would then create a client statement which would show a $90.00 balance due on the session.
NOTE: You could make an additional adjustment (at your discretion) if you wanted to cut the patient a break. For example, if you didn't want to charge the full 90.00 extra to the patient, then you could enter an adjustment on the session to bring the amount due down a bit. But that is completely up to you.
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