You’ve sold it, now what happens…

Recently, co-blogger Bob V sent me a link from his list-serve that concerned
co-payments:

I have a client, who currently has UHC RPPO, the copay is $0 for
her PCP. I find out today that her Primary care doctor has been charging her a
$35 copay every time she sees her. The doctor is clearly listed as a
"Primary Care Physician" in the directory, and not a specialist, So I
cannot figure out why she would get billed a copay like this. I have not had a
chance to contact the doctor yet to investigate, but when I found this out, I
was outraged, i wanted to go down to her doctor's office and demand they give
her her money back.

While I admire this agent's chivalry, before
he cold-cocks a doctor, maybe we should review the situation, beginning with:
what is a co-payment? A co-payment is an amount of money a patient agrees to
pay a physician for an appointment, as set by the insurance company, which the
physician agrees to accept. These co-payments are to be collected at time of
service, hopefully before the appointment ( but I digress). Some companies determine
the co-payment by the type of provider (eg  Family Practice or Specialist) or by appointment type (eg Physical Therapy), or even a single co-payment regardless of
the appointment type or provider. In this situation, the Family Practice Doctor
was charging the higher Specialist co-payment to the patient.

Let’s assume that the doctor is collecting the higher co-payment. When the doctor electronically bills t...

Source: InsureBlog - October 28, 2013 Category: Medical Lawyers and Insurers Source Type: blogs