Co-Payment

Co-payment or co-pay is a predetermined (flat) fee, based on a contract between an employer or patient and an insurance company A co-payment that a patient pays for health care services is in addition as an out of pocket expense to what the insurance company covers for the service provided. A co-pay is separate from a deductible and co-insurance. For example, a patient may have coverage through Blue Cross and Blue Shield. The policy may require the patient to pay a $10 copayment for each office visit, regardless of the type or level of services provided during the visit. A patient coming in for daily blod pressure checks could be required to pay the co-pay for each BP check visit. Co-payments are not usually specified by percentages. Co-pays are usually paid at the time of service. Some providers will bill the patient for the co-pays. A huge question that is always asked is, “Can we write off the co-pay owed by the patient. This question has NO easy answer. Again, the co-pay is a contractual amount that the patient is required to pay. Writing off co-pays on a routine basis could be determined by a Government Inspector as an incentive to have the paient make referrals to the provider. The insurance company could take the position that writing off a co-pay is a contract violation. The key word with doing a write off is routine. Each write off should be on a case by case basis. The patient may be financially unable to pay the co-pay. If, so then it would be permissible to write off the co-pays. There are at least three (3) acceptable means of writing off what a patient may owe. (1) The provider has made every effort to make collection on what is owed and this includes a debt collection agency. (2) if it would cost more to collect than what is owed. For example, the patient owes $1.95. It costs $10 in administrative expenses to bill a patient. Therefore the cost to collect is more than what is owed. The $1,85 could ne adjusted off as a small balance adjustment, and (3) The patient is financially unable to pay. The patient must prove they are financially unable to pay. This can be in the form of wage statements, bank statement, tax statement and lists of monthly bills such as electricity, food, and other bills.

COBRA Consolidated Omnibus Budget Reconciliation Act.  

This is a Federal Law that allows a worker to continue to purchase employer paid health insurance for up to 18 months if you lose your job or your coverage is otherwise terminated. For example, your employer provides you with health insurance through United Healthcare as a benefit of employment. The employer is going out of business or you leave for another job. Under COBRA, you can continue to keep your United Healthcare coverage when you leave your employer. 

The catch to this is that YOU must continue to pay the premiums that your employer paid. Some people decline this because they cant afford the premiums. If the patient kept the COBRA coverage make sure you verify that the coverage is still in effect at the time of service. The patient may present the United healthcare insurance card but you find out that the patient did not pay the premiums, so the coverage was terminated. 

Health Coverage and Medical Terms

Allowed Amount 

Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. 

Appeal 

A request for your health insurer or plan to review a decision or a grievance again.

Balance Billing 

When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services. 

Co-insurance 

Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

Complications of Pregnancy 

Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a nonemergency caesarean section aren’t complications of pregnancy. 

Co-payment 

A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.