A common oversight in many medical offices is the lack of awareness that collecting a copay is a requirement, especially if you're contracted with an insurance company. It's crucial to read and understand the contracts you sign as a participant with these payers, as they often outline what you can collect from patients, the expected amounts, and the mention of co-pay.

What is Co-pay

Co-pay is a  contract between the patient and the insurance company, agreed upon when the patient signs up for coverage. The co-pay is meant to be paid at the time of service, and the specific amount depends on the type of healthcare provider they're visiting – whether it's a general practice, primary care, or a specialist.

In the past, copays didn't really exist, and when they did, it was a fixed amount, no matter the provider or specialty. Nowadays, plans break it down into two, three, or even four different amounts, including primary care, specialty, urgent care, and emergency room visits. As a business owner, it's vital to ensure that your front desk staff understands what to ask for, when, and how to approach patients.

Many patients are aware of their co-pay, but sometimes they act surprised or claim they don't have the money that day. It's advisable to give patients a one-time pass (a "get out of jail free card") for their first missed payment. However, beyond that, expect patients to pay at the time of service as per insurance requirements.

Patient Situtations with Co-pay

Patients often misunderstand that the co-pay is an agreement between themselves and their insurance, mistakenly thinking the doctor's office is involved. Front desk staff should be prepared with appropriate responses to address these situations. It's about setting expectations and ensuring a smooth process for both the patient and the medical office.

For instance, let your staff know they can inform patients that unfortunately, the co-pay is an agreement between them and their insurance company. Example: "Per our contract, to see you as a patient, we need to collect it at the time of service". Also, let them know they can tell the patient that "we understand things happen, like leaving your wallet at home or being between paydays, so we can bill you for the co-pay this time. However, moving forward, we will have to collect it at the time of service."

Being direct, kind, and understanding can go a long way. You can  also ask the staff to add pop-ups in those patients' charts so that you can know they used their "get out of jail free" card, and they will be expected to pay moving forward, documented.

Guide to Efficient Collections

If you don't collect the co-pay at the time of service because you don't see they have a co-pay or they don't have the money, it can get expensive to send out statements just for a $10 co-pay. Think of all the work that goes into printing statements, mailing them, the cost of paper, ink, staff time to process payments, how long it waits on your books, and it's not worth it because it's been sitting out there for three months, a measly $10, $20. And when I say measly, I don't mean it doesn't add up. It's great to have, but it loses its worth after some time. It's crucial to emphasize this to your staff and explain why it's important to collect at the time of service.

Equinox Medbilling Solutions' EHR systems will tell you how much the co-pay is for the specialist, primary care, and urgent care. There should be a place for you to input that co-pay so it prompts them every time the patient checks in to collect that amount. A lot of times, the challenge is entering that amount into the appropriate place. You can check eligibility and benefits; it will tell you the co-pay amount, but they don't automatically populate that into the insurance. So you have to make sure your staff member goes into their insurance screen and enters that co-pay amount.

It's up to you whether you want to collect some money upfront as a deposit or a payment towards those deductibles and co-insurances. The co-pays are crucial. They lose their value if you have to bill them out because it costs you more money to collect that money. It's an agreement between the patient and the insurance company, and also in your contracted agreement as a participant, you agreed to collect that amount. It's one of those things where you're letting the patients know that you're aware they'll have a cost-share amount, and you'll be diligent in collecting that and maybe you'll be more at the forefront of their mind, making sure they pay when they come in for visits and receive statements for account balances.

Conclusion

I encourage you to go back, read your contracts with all your payers to understand this, and also ensure you can educate your front office staff to collect that money upfront.

It's better in the long run, You're also fulfilling those obligations you agreed to with those insurance companies. You cannot consistently waive those co-pays for people because you can get in a lot of trouble with Medicare or Medicaid and the insurance companies with which you have signed agreements.

So if there is a special circumstance where a patient is going through financial struggles and you want to do this as a mercy and grace situation, make sure you have a policy for when you make that exception. It truly should be a rare exception, and you must document why. If you were ever audited and questioned why you waived that co-pay for a specific patient in that specific circumstance, you can go back and say they lost their job, their spouse just died, they had no income, and they really needed to be seen. As long as you have a policy about that situation, it's used rarely, and you document that specific instance in the patient's chart of why you waived that co-pay or that deductible or whatever it may be. If you're facing difficulties collecting your co-pay, Equinox MedBilling Solutions is here to assist you so go ahead and book a call with us right now. These calls are free, they last about 30 minutes and they come with no obligations whatsoever.