Charging Patients for Covered Service

March 1, 2009

We are promoting sports physicals with ads that promise “Parents will not pay more than $25.” If the patient is a cash pay, we only charge $25. However, if the patient has insurance we bill out a well-child exam at the full price, switch the patient back to a status of cash pay after we have printed/sent the claim, and leave the insurance-billed charge at the higher rate. If the insurance pays, we adjust an additional amount, on top of their “contract” adjustment or whatever is applied to deductible/etc., to bring the balance due from the patient to $25. What if the patient is insured but we simply don’t bill the payer and instead charge the patients $25 cash? Can you help us decide what’s appropriate?

Question: We are promoting sports physicals with ads that promise “Parents will not pay more than $25.”

If the patient is a cash pay, we only charge $25. However, if the patient has insurance we bill out a well-child exam at the full price, switch the patient back to a status of cash pay after we have printed/sent the claim, and leave the insurance-billed charge at the higher rate. If the insurance pays, we adjust an additional amount, on top of their “contract” adjustment or whatever is applied to deductible/etc., to bring the balance due from the patient to $25.

What if the patient is insured but we simply don’t bill the payer and instead charge the patients $25 cash?

Can you help us decide what’s appropriate?

Answer: Let me spell this out in case I missed something:

An insured patient comes in. If the patient responsibility - copay, deductible, whatever - is less than $25, the practice adds another charge. To me, this is double billing. The insurance company paid already. Why should the patient pay also?

If the patient responsibility is more than $25, the practice cuts its charges so the patient only pays $25. No way. The patient has to pay the copay required by the payer, for one thing. The practice can’t discount the copay. For another thing, why in the world would the practice collect less than it is owed?

If the physicals are a covered service, you have to bill for them (otherwise, you are essentially requiring the patient to pay for the service twice). If the physicals are not a covered service, you can provide it as a self-pay or cash service.

In addition, I’m not crazy about always using well-visit codes for sports exams. Are the physicians really doing a full preventive visit?

CPT Assistant has suggested using a problem-focused code for exams of a more limited nature.

I’d make sure the practice isn’t double billing nor in violation of its agreements with payers to collect the full copay and deductible.