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!