When a co-payment should be collected regardless of who and where the service was provided?
In the ever changing world of health care and overall rising costs, co-payments are no longer ONLY applied for certain specialties and are NOT always driven by Place of Service or E&M Visits. The industry has increased cost shifting from insurance plan to patient creating a more self-pay environment. In the bigger scheme of this issue, some plans are now applying co-payments as high as $100.00, deductibles and co-insurances to diagnostic and radiological (OB Ultrasound) services regardless of where and who performed the services.
Example: A patient opts for an insurance plan which has a less monthly premium through their employer. These particular plans usually carry high deductibles and have limited coverage for Obstetrical care when a patient elects the inexpensive health care plan. Inexpensive plans = Limited OB or NO Coverage = High Deductibles resulting in a cost shift from plan to patient (Higher out of pocket costs).
What does this mean for the provider? Providers and Facilities are faced with difficulties to collect these funds up front causing additional administrative costs and are burdened in their efforts to collect these balances. These exertions result in overall losses in the long term. Some patients may incur deductibles as high as $12,000 per year causing them to be Self-Pay throughout the majority of their obstetrical care. In some cases, some patients are unable to pay. The patient did not educate themselves when they chose the plan. They felt, less monthly premiums, more cash in their pockets after payroll. What they didn’t think about, “What if they become pregnant and high risk? Unfortunately, some practices learn this after the services are rendered since they do not have the man power to perform insurance verification efforts.
We strongly advise that your insurance verification representative or someone in your office contacts the payer on a case to case basis to determine the patient’s coverage and financial responsibility towards the specific service being provided to assist in collecting for services upfront. Moreover, it will provide education to the practice and patient regarding their insurance plan provisions and coverage.