Copayments/Coinsurance

Most members' health coverage includes a copayment, a deductible amount, and/or coinsurance.

Using the HNS Verification of Benefits Form, be sure to verify the specific amount of the member's copayment and/or deductible/coinsurance prior to providing any services to the member.

If there are services that are non-covered, remember to have your patient (or legal guardian) sign a Non-Covered Services Waiver prior to rendering the service and be sure to retain a copy of this waiver in the patient's health care record.

For covered services provided, no money can be collected at the time of service in excess of the applicable co-payments, 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.  

Please note:  If the contracted allowable for the service or services provided is less than the co-payment, providers may only collect that amount.  If the copayment exceeds the sum of the allowables for the covered services provided, the provider must collect the co-payment amount.

Exception:  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 cannot be honored UNLESS the patient, or legal guardian has signed and dated a written request not to file their health care claims and the request is maintained in the health care record.

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 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 Providers may not bill the member for the discounted or disallowed amount for covered services rendered to any member of an 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/deductible/coinsurance amount than the amount indicated on the member's subscriber ID card.

Absent true financial hardship that is properly documented in the patient’s health care record, (including documented evidence of such hardship) providers must collect the full copayment/deductible/coinsurance for all covered services provided for every patient visit.

Waiving and/or reducing copayments, deductibles, and/or coinsurance are violations of the terms of the HNS Practitioner’s Participation Agreement and HNS contracted payor policies.

For Medicare: Failure to comply for individuals covered by federally funded health care plans is a violation of federal regulations.  Failure to comply with such laws 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 

Please review the HNS Financial Hardship Policy and Confidential Financial Hardship Worksheet.

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. A statement that the practice will not waive or reduce copayments, coinsurance, or deductibles.
   
   
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.