Reporting Co-payment Amounts on Claims

by JAJ


I think I'm over-thinking this and driving myself batty:

Should the copayment be listed as the applied amount/patient amount paid on a claim? My hunch is no, since the copayment doesn't apply to the deductible (and should show up on an EOB with a PR code, at which time the copayment could then be deducted from the patient's account).

I'm asking because I'm billing for a provider who has a base rate of $120, and previously (prior to using my services) they were deducting the copayment amount to get the service line charge. For example, if the patient has a $40 copay, they bill $80 instead of $120 for a service line. I'm thinking this is wrong, because it would reduce any coinsurance amount, since coinsurance is based on a percentage of the charges; but of course now I'm second-guessing myself.

So really there are two questions:
1. should copayment be listed on the claim, and
2. if not, should the base rate be used for the service lines, or should I deduct the copayment amount from the base rate for the service line charge?

Thanks a bunch--love your site!

You are correct - the co-payment should not be reflected in the amount shown on the claim. In your example you would just show $120 for the procedure on the claim. Of course the insurance provider will only pay the contract amount and the rest is write-off. Your provider may be hurting themselves by deducting the co-pay if in this example the insurance payer allows more than $80 for this procedure.

Of course the EOB will reflect the allowed amount, write-off, etc. The co-pay is usually shown as a patient responsibility or may even be identified as a co-pay.

Great question - Hope we've answered it - if now please let us know. Thanks for visiting the site!

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Oct 19, 2012
Double Billing of CoPays
by: F&RS

My elderly Mom just received a bill for 5 copays which she already paid at her office visits. I wrote the checks & also have the paid receipts as well as cancelled check documentation. When speaking to the medical billing co., they first denied it was anything but a minor billing error. However, this was the second time I caught them doing this dating back from May & now October. The rebilling was from appts. in Feb & now March & April. Clearly they have not corrected the error. I have the proof to dismiss the bill. I'm concerned that hundreds if not thousands have likewise been billed but have neither the documentation or wherewithal to prove it. And they could very well be paying twice. That's double billing & isn't that illegal? Shouldn't the co pay be reflected on United Healthcare's EOB & also on the doctors bill (issued by the medical billing co.)? Interestingly, when I called to complain, they had the paid data. So if it's already in their system, why are they billing? Shouldn't they be pulling that data into billing or crosschecking it against Dr deposits? Is there something systemically illegal going on?

Aug 05, 2012
Thanks for the response!
by: JAJ

Thanks for know how it is when you start thinking about something and you think the know the answer, but the more you think about it, the less sure you become...

I appreciate it!

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