Health Network Solutions, Inc. : Co-payment Collection

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COpayment/COinsurance Collection & Patient responsibility

Most member's health coverage includes a copayment, a deductible amount and/or coinsurance. It is very important that you verify the exact amount of the member's copayment and/or deductible/coinsurance prior to providing any services to the member.

When a patient comes into your office, it is very important that you call to verify benefits and eligibility on the patient and ask the insurance plan specifically about services prior to rendering the services. If there are services that are non-covered, you must have the patient sign a Patient Waiver for Non-Covered Services prior to the services being rendered.

No money can be collected at the time of service other than any applicable copayments, deductibles and/or coinsurance. Some plans only require a copayment, while others may have a deductible and coinsurance. Always ask whether the member’s plan has a copayment, coinsurance or deductible when verifying benefits.
Exception to this policy: If a patient does not wish to have their claims filed to their health care plan, providers must comply with this request. However, such requests must be documented in the patient's health care record and the patient must be required to pay in full at the time service is provided.)

If you do not collect the appropriate copay, coinsurance and/or deductible, when you receive your Explanation of Benefit(EOB) or Notification of Payment(NOP), you may bill the patient for any copayment, deductible or coinsurance up to the plan’s allowed amount.

If, when you receive your EOB/NOP, some of the services have been applied to member responsibility as a non-covered service(s), it is important to remember that you cannot balance bill or collect those monies from the patient, UNLESS you obtained a signed waiver from the patient for those specific non-covered services prior to rendering the service(s). All such waivers must be maintained in the patient's health care record.

HNS Provider’s may not bill the member for the discounted or disallowed amount for covered services rendered to any member of a HNS contracted plan.

As a participating provider you may only bill the patient for non-covered services (if you have received a signed waiver for those services prior to being rendered) and may only collect the applicable deductible, copayment or coinsurance amounts for covered services.

Waiving Copayments, Deductibles and Coinsurance

HNS providers cannot waive, reduce or discount any copayments, deductibles, or coinsurances. This includes accepting a "lower" copayment amount than the amount indicated on the member's subscriber ID card, discounting copayments and/or waiving copayments including services deemed “professional courtesy” and TWIP (take what insurance pays).

Absent true financial hardship (with complete, current, supporting, documented evidence of such hardship maintained in the patient’s health record, please see below), the full amount of the copayment as well as ALL copayments, deductibles and coinsurance due and owed must be collected by all network providers for every patient visit.

For HNS Contracts:
Failure to consistently comply for individuals covered by a HNS contracted payor is in violation of the policies of our contracted payors and may result in the termination of your status as a HNS participating provider.

For Medicare:
Failure to comply for individuals covered by Medicare is a violation of the Federal False Claims Act, Federal Anti-Kickback Statute, and the Federal and State Insurance Fraud Laws. Failure to comply may result in civil money penalties in accordance with the new provision section 1128 A(a)(5) of the Health
Insurance Portability and Accountability Act of 1996 [section 231(h) (HIPAA).

For HNS contracts, no money can be collected at the time of service unless there is a copayment and/or deductible amount stated on the ID card. Some plans only require a copayment, while others may have a deductible and coinsurance. Always ask whether the member’s plan has a copayment or deductible when verifying benefits. Remember, you cannot waive or reduce copays!

If you did not collect the member's copayment, deductible or coinsurance at the time of service, once you receive your Explanation of Payment, you may bill the member for any copayment, deductible or coinsurance up to the plan’s allowed amount.

True Financial Hardship

If a patient has a financial hardship, there are possible steps to take to assist them, other than waiving the

copayment, deductible, and/or coinsurance. You might consider establishing monthly payment plans that the patient can afford. Additionally, you might consider referring the patient to the local social security office for assistance which can help the patient with all medical expenses, not just chiropractic care. Should the patient refuse options such as this, they may not qualify as a "financial hardship."

A financial hardship policy should include:

1. Standards for waiving copays, deductibles, and/or coinsurance that indicate that only objective, reasonable criteria are consistently utilized for every patient presenting with a financial hardship.

2. A printed financial worksheet that such patients must complete, to provide the information needed to determine if the patient's financial position meets the criteria of your policy.

3. A designated person in your practice who is the only person with authority to grant the waiver.

4. This person should maintain a listing of all patients who receive such waivers.

Please review our sample template Financial Hardship Policy and Confidential Financial Worksheet.