No co pays

[Dr. Ice]

I recently found out about a practice that never charges co-pays. Its a chiro, multiple PTs a neurologist and a pain doc. The patients can keep going and never pay a co pay. The patients get PT, evaluated by the docs, and chiro manipulation every couple of days. They are not exclusively comp or auto and deal with a medicare and a lot of private insurances. What kind of practice set up is this? Is it even legal?

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[Aether2000]

Definitely medicare fraud...probably insurance fraud

 

[pastafan]

Definitely not legal involving any insurer.

 

[emd123]

FWIW: here's my understanding of how it works, though I'm not a lawyer, so don't take this as legal advice. You must at least bill for the copays for it to be legal. If you routinely waive copays, it could be seen as an inducement, like you're paying the patient (the amount of the copay) to see you over competitors. I'm told that there's no requirement of how, when, if, or how aggressively you try to collect on it, once billed.

 

[pastafan]

Physicians have been prosecuted for insurance fraud for practices like this. This is the reasoning as explained to me: if you routinely bill $100 for a procedure the insurance company is paying you $80 based on the amount that you charge and your contract. In other words, if your contract price without is $100 the insurance company pays 80 then the patient has a 20 copay. If you never collect a copay then your true charge is $80 and the insurance company only owes you $64. You are obligated by contract to collect copays.

 

[Paddington]

On another forum there was recently a debate on socialized healthcare. In a majority of countries with supposedly free healthcare they do have copays. Copays are very important for reducing healthcare system overuse and cost, IMO.

Am I surprised a Pain practice, of all practices, is not collecting copays? Not really. If you're in the job market hunting around, take a close look because many if not most Pain doctors are doing something shady to get some edge over the competition in a ultra competitive market and era of plummeting reimbursements.

 

[Jcm800]

it is true, you can "bill" for co-pays. you need to "collect" co-pays but from what i understand, however, it doesn't HAVE to be at time of service. However, in out experience, if you DO NOT collect a copay at time of service, you have almost no chance of EVER collecting it. Which is the reason most practices aggressively collect co-pays at time of service. If your goal is for something else, such as the practice described above, then they may not be "waiving" co-pays, per se. They may be billing for them, with the understanding that they don't "have" to pay them. Which is still not kosher, but i bet a lot harder to prove that you are doing something shady.

I can't imagine trying to get patients in by waiving co-pays. I just want my money for what i did, and even that apparently is too much to ask for these days...

 

[Dr. Ice]

Well as I understand it this practice is mainly out of network so I'm sure they are charging a **** ton of money for their services and as the insurance companies have no way to regulate payment for out of network docs it becomes the wild Wild West. I'm sure there are several practices and docs that do this and it's not just pain docs. I know of a cardiologist who was charging 15k for a cath and getting paid close to what he charged out of network.

it is true, you can "bill" for co-pays. you need to "collect" co-pays but from what i understand, however, it doesn't HAVE to be at time of service. However, in out experience, if you DO NOT collect a copay at time of service, you have almost no chance of EVER collecting it. Which is the reason most practices aggressively collect co-pays at time of service. If your goal is for something else, such as the practice described above, then they may not be "waiving" co-pays, per se. They may be billing for them, with the understanding that they don't "have" to pay them. Which is still not kosher, but i bet a lot harder to prove that you are doing something shady.

I can't imagine trying to get patients in by waiving co-pays. I just want my money for what i did, and even that apparently is too much to ask for these days...

 

[emd123]

Well as I understand it this practice is mainly out of network so I'm sure they are charging a **** ton of money for their services and as the insurance companies have no way to regulate payment for out of network docs it becomes the wild Wild West. I'm sure there are several practices and docs that do this and it's not just pain docs. I know of a cardiologist who was charging 15k for a cath and getting paid close to what he charged out of network.

I get how that works for cards, if the cath is emergent, then the patient and insurer are stuck paying the higher out-of-network fees since they didn't have time to shop around. But how would this even work for Pain? Most pain patients that are told their provider is out of network seem to immediately take a hike and move along to someone in-network so it's more affordable. How is anyone convincing a significant amount of patients to come to them, and pay the higher fees that are out-of-network? Is it only these shady copay-waiver scams or is there some other legitimate way of attracting out of network patients to get higher fees?

 

[deleted480308]

I get how that works for cards, if the cath is emergent, then the patient and insurer are stuck paying the higher out-of-network fees since they didn't have time to shop around. But how would this even work for Pain? Most pain patients that are told their provider is out of network seem to immediately take a hike and move along to someone in-network so it's more affordable. How is anyone convincing a significant amount of patients to come to them, and pay the higher fees that are out-of-network? Is it only these shady copay-waiver scams or is there some other legitimate way of attracting out of network patients to get higher fees?

If you are the only doc that will write those scrips they want, they will pay out of network to see you

 

[anbuitachi]

didn't realize not charging copay is illegal... is opening a free clinic illegal too? [not charging anything]. or what about not charging copay to certain ppl?

my PMD didn't charge me copay after i stayed w/ him for years.. did i unknowingly participate in fraud..

 

[Ducttape]

if your insurance doesnt mandate copay, your PMD did not participate in fraud.

whats illegal is an office not charging copay while billing the patient's insurance company.

 

[ampaphb]

80% of nothing is nothing, so a free clinic is perfectly fine.
You are not obligated to collect the co-pay. You are obligated to make a good faith effort to do so. Requesting it at the time of service, and then sending follow-up letters constitutes good faith in my state. You are not, however, required to send them to collections.