Medical CoPay Overpaid

[Fern Modena]

I have a 15% copay on most of my medical procedures. Now this isn't 15% of what they bill, but 15% of what the insurance company actually pays. Most of the doctors' offices want to collect the copay up front. And they don't properly "guess" how much that should be. My family doctor's office was charging me @15., although the correct amount was $7.50--$10., depending on what was done. Every so often I tell them I have a credit and refuse to pay (they make a fuss, but I win). This recently happened at the eye doctor's as well. My ortho doctor and hand doctor do not take payments in advance.

I've had several situations where there have been overpayments and they've conveniently forgotten about this and tried to keep them, collect more, etc. I went to physical therapy twice a week for six weeks. I paid $8. copay each time. When I got the bill they showed that I'd paid less than half the time. Luckily I paid with my debit card, so I could go back and see the payments on line. I called, and they "found the payments," and apologized for the fact that they hadn't posted. This happened TWICE.

I had a series of MRIs last year in July. I had to pay $136. up front to get it done. I kept looking for the insurance EOB (Explanation of Benefits), but it never came. Last night I finally "found it." It had been submitted under a totally different company name. Turns out when I checked on the back of my check, same name. Overpayment? You betcha. $40. I called today, and they said they don't automatically check for overpayments. Like, yeah, they don't send out bills if there is an overpayment so that the patient might catch it. Do I want her to apply for a refund for me? It'll "only" take 4 to 6 weeks. GRRR...

It seems that whenever there is an overpayment, NONE of the medical providers provide a statement. How crooked is that?

Just needed to vent.

Fern

 

[Liz Wolf-Spada]

Fern I recently discovered that my Blue Shield EOB's are available online. My plan has $10 office copays. Anything else. I don't pay till after I get the EOB.
Liz

 

[Fern Modena]

My EOBs are available online, too, but this company used a different name when requesting payment, so I didn't catch it. And my copay varies. I'd obviously prefer *not* to prepay since so many cause overpayments, but most insist. That way they can keep your money forever if you don't catch it...

Fern

 

[Rose Pink]

Can you prepay a smaller amount? In other words, just tell them your co-pay is $10 and then let them bill you for the rest if it is more than that?

Usually I just pay a co-pay but for some services there is a co-insurance (percentage) rather than a set co-pay. In those cases the provider has usually called the insurance carrier in advance to find out what they will pay.

Sorry you are having such a struggle. Maybe you need a new doctor?

 

[laxmom]

I am going to come at this from the other side so don't flame me, please. Not making excuses for anyone but trying to look at it from another point of view. There are things that I didn't realize until I started working on the other side of the counter.

We try to do the same in collecting the coinsurance in our office. Why? Because insurance companies are making it harder and harder for Dr.'s to get paid. For the work we do tomorrow, my Dr. will not be paid for a minimum of 6-8 weeks. I know I wouldn't be happy with it. In many cases, it takes months, if at all. I mean 6 months or more to recieve a payment. Have you wondered why so many Dr'.s are getting out of network with more and more insurance companies? There is your answer. They are also now refusing to pay on more and more services that patients need for their conditions to improve but by contract, we aren't allowed to bill the patient if the insurance company refuses to pay. In other words, we are forced to make a choice between services that our patient needs, getting paid or getting in trouble for providing a service that we don't bill for. (yes, a Dr. can get in as much trouble for not billing for something as he would if he billed for something he didn't do.) As insurance companies get harder and harder to deal with, things will, unfortunately get more and more difficult for us, the patients. I submitted a claim yesterday for the 5th time since last October because of no insurance company response. When they do respond, it will be that we have exceeded the timely filing limit.

Now for another problem. As we all know, insurance benefits have declined.
When I started working at this office, the average copay was $10-15. Now I see $40 and $50 copays on a regular basis with most falling between $25 and $35. Deductibles have gone from a few hundred to several thousand with 3-5 thousand being the norm. The average patient pays no attention to how their benefits change from year to year and most come to our office not having a clue of what their responsibility is. Why? Because most benefit packages are written for people with PHD's or legal backgrounds. The result is more and more people being sent to collections for lack of payment. And the ones sent most often in our office? They are the ones with the percentage coinsurance mentioned previously. They are harder to estimate and for a long time we haven't even tried. Now, it is becoming necessary to reconsider that policy. We are here to help people but we are also a business that has responsibilities that we must also meet.

Most Dr's office purchase billing software. I know ours does not show any visit that has been paid in full nor any credit that has been accrued. We can't change that; it is what we bought. Now, that said, we do check every account as patients check out for overpayments and apply them to upcoming visits or, if the credit is big enough, we will cut them a check. But because the insurance companies are taking so long to pay, it could be months and many visits before that credit shows in our system. We always get the EOB's after the patient - usually by a couple of weeks. Also, some Dr's offices use outside billing companies who send statements and recieve/post payments. The person behind the counter that you are talking to probably will not have any idea of the status of your account unless you ask.

I can't speak for your Dr's office but I can speak for ours. We don't try to rip anyone off intentionally; we are merely trying to do business in an increasing difficult environment. I am sorry that you are so frustrated, Fern, but I honestly see it getting worse before it gets better with the healthcare industry as a whole.

 

[Liz Wolf-Spada]

As there is no way to estimate what the % will be applied to, as it is up to the contracted amount, it seems doctor's are out of line insisting on prepayment unless it is a set copay.
Liz

 

[Rose Pink]

Medicare calls that "enticement" and considers it fraud. I was not aware that other insurance companies were also doing that. Thanks for the info.

Thanks, also, for telling the other side of the story. I worked briefly for a small clinic. The sole medical practitioner started sending her patients to an outside lab to have their blood work done. If she drew the blood and sent it to the lab, the insurance company would not pay her even the cost of the supplies she used. In other words, she lost money each time she did a blood draw. It was inconvenient for the patients to have to go somewhere else for their labs, but necessitated by the insurance companies' refusal to reimburse the clinic's costs.

Now, maybe someone will tell the insurance companies' side of the story.

 

[Rose Pink]

As there is no way to estimate what the % will be applied to, as it is up to the contracted amount, it seems doctor's are out of line insisting on prepayment unless it is a set copay.
Liz

Seems to me it would be less of an accounting nightmare if they waited rather than estimating. How much time is chewed up billing for the remainder if the initial estimate was too low or in having to research and cut a check if the initial estimate was too high? But then they would have to bill each and every time if they waited. With the estimates, they probably get some correct part of the time and then don't have to bill or refund.

I don't see the doctors as being "out of line," however, for the reasons LaxMom noted. Their costs of doing business are high because of the ridiculous (and, imo, evil) policies of the insurance companies.

 

[Fern Modena]

laxmom (and others),
Its not just one medical provider who has overcharged me and then not refunded the overage. I can think of two doctors, a radiologist, and a physical therapy off the top of my head. It seems to be a way of doing business around here.

I'm well aware of what my coverage is, and what percentage my coinsurance (that's the correct term actually) should be, but if I don't know how much they will be paid, I don't know what the right amount will be. And neither do the receptionists, but they generally insist on some figure, one that guarantees an overage. Every so often I insist I won't pay, if I know there is an overage, and then a big hassle ensues while they check (this takes perhaps ten minutes, with other people waiting to register, etc.).

I know that the receptionists don't know if/how much a patient has in overage/money due back to them. But their should be a way of showing it. They verify the insurance each time to make sure they will be paid, so why can't they do that?

As for doctors waiting for payment, I am sure that happens with many insurance companies, but not mine. I have United Healthcare, and if the doctor's office/billers bill in a timely manner they are paid quickly. My last doctor's appointment was 06/20/08. The processing was done on 06/25/08. I don't know how long it is after that until they actually see the money, but I am guessing it is under 14 days and certainly not months in this case.

It all boils down to this: In this last case, they've had my money for over a year and made no attempt to contact me and give it back. And the biller admitted that they never would do so. If I didn't ask, I'd never get it. How convenient for them...

Fern

 

[caribbean]

Fern-

I know your frustration. I actually had a Dr office "write off" my overpayment. When my EOB came, I realized I had a credit, but since I was due to go back in 6 months, I let it ride. At the next visit when they asked for another payment, I said I should have a credit that should about cover it. She looked online and said my account had a zero balance. I refused to pay and demanded a printout of my entire account acitivity for the last 3 years. I got it in the mail a week or so later and found a line item where -$40 had been entered. When I called the explanation I got was that since I had not requested a refund, they just zero balances out after 4 months. Since that time I have my own policy where I refuse to make anything more than my co-pay until after my insurance pays and the Dr pays me.

Maybe you can go back and see how much you have been overpaying on average, say a percentage. Then when they ask for an estimated payment, subtract that percentage and tell them to bill you for the rest after they have received the insurance payment. Tell them you have your own policy.

Good Luck

 

[bogey21]

My dentist does it different. I have to pay the whole bill at time of service; they immediately (while I am in the office) submit the claim electronically to my insurance company; who then mails me a check which I usually receive in 2 - 3 weeks. Pretty efficient, but of course I have to have the money to pay up front

George

 

[caribbean]

George-

I think I would find another dentist.

 

[TerriJ]

Just like the posts suggest, we all need to carefully check our accounts and payments. When I call the Dr. to ask for a refund of overpayment, they seem surprised. I know they expect me to pay any amount I owe them, I am simply asking for the same treatment.

 

[laxmom]

laxmom (and others),
Its not just one medical provider who has overcharged me and then not refunded the overage. I can think of two doctors, a radiologist, and a physical therapy off the top of my head. It seems to be a way of doing business around here.

I'm well aware of what my coverage is, and what percentage my coinsurance (that's the correct term actually) should be, but if I don't know how much they will be paid, I don't know what the right amount will be. And neither do the receptionists, but they generally insist on some figure, one that guarantees an overage. Every so often I insist I won't pay, if I know there is an overage, and then a big hassle ensues while they check (this takes perhaps ten minutes, with other people waiting to register, etc.).

I know that the receptionists don't know if/how much a patient has in overage/money due back to them. But their should be a way of showing it. They verify the insurance each time to make sure they will be paid, so why can't they do that?

As for doctors waiting for payment, I am sure that happens with many insurance companies, but not mine. I have United Healthcare, and if the doctor's office/billers bill in a timely manner they are paid quickly. My last doctor's appointment was 06/20/08. The processing was done on 06/25/08. I don't know how long it is after that until they actually see the money, but I am guessing it is under 14 days and certainly not months in this case.

It all boils down to this: In this last case, they've had my money for over a year and made no attempt to contact me and give it back. And the biller admitted that they never would do so. If I didn't ask, I'd never get it. How convenient for them...

Fern

Actually, Fern, that insurance company is our worst nightmare. Many Dr.'s here are dropping them because of issues with getting paid. They ignore our claims and then state untimely filing, refusing to pay when we have a computer record that the claims were sent multiple times and accepted by their system. They say a patient does not need preauthorization and then refuse to pay saying they need preauth. We have sent them to the state Department of Insurance more times than I can count. We have been awarded payment in every one of our complaints but rarely do they pay even then. By then, we are looking at an 8-9 month process. They are in some serious hotwater at the state level here. Our patients with that particular company are not getting the benefits that they are paying for. Please keep your eyes on those EOB's.

No insurance company is without issues anymore. My advice to anyone is to know your coverage, check your EOB's and if they make a mistake, persue it. The mistakes they make are just amazing sometimes and many people would just pay the bill not realizing there is an issue. Sometimes, I think they are banking on it. We go over every one for errors before posting it to the patients account. I am sure most offices don't.

 

[laxmom]

My dentist does it different. I have to pay the whole bill at time of service; they immediately (while I am in the office) submit the claim electronically to my insurance company; who then mails me a check which I usually receive in 2 - 3 weeks. Pretty efficient, but of course I have to have the money to pay up front

George

That is because your Dentist does not accept assignment. When we lived upstate, every Dr. we saw was like that and that was 15 years ago. This is going to become more the norm as insurance companies work harder and harder to find reasons not to pay while keeping their investors happy.

Here, a Dr. sent letters to select patients inviting them to be part of his new practice. He was charging them $800 per year-like a retainer- to be their physician. So, they would be paying this fee, paying for insurance but not able to submit anything for reimbursement as there would be no HICFA for his services. This one scares me. We don't go to a Dr. but once in a blue moon, thank goodness. So we would be paying nearly $800 per visit in the end.

Legally, I think they have to wait longer than 4 months to zero that credit out and count it as unclaimed funds. At least here they do. Also, remember that the average patient may have a few Dr's bills to keep track of while the office staff may have thousands of patients. It is a tuff one to juggle it all and things do happen. In our office, we can easily enter a patients charges but to check their balance and see how things were processed, we have to go deeper into their account and open each date of service individually so it isn't something we do with every patient. Only those that we expect problems unless asked.

 

[Fern Modena]

Here is how I think the billing process *should* work:

• I go to for a medical appointment.
• They take a coinsurance, whatever amount they think is proper and give me a receipt.
• Their biller posts this coinsurance to my account
• They bill the insurance

Ok, I think all that happens...but then, here's what should happen next:

• Medical provider gets EOB
• I get EOB
• Medical provider gets payment as per EOB
• Medical provider's biller posts the payment to my account
• Medical provider's biller then decides if there is a balance due to them, or an overpayment, which is a refund due to me.
• Medical provider's biller then sends out a statement which includes either a bill, or if an overpayment, a check.

Unfortunately the last step doesn't happen that way. If there is a balance due to the medical provider, they send a bill. If there is a zero balance or an overpayment, they simply do NOT send out a statement, much less a check. And no matter how you cut it, that's wrong. It can't be that they "don't know," because when the biller posts the payment they *do* know the balance. Maybe their system is set up to send a bill only if *I* owe them, but that's wrong. Its unethical to hold my money and not let me know that I have a balance due to me. I don't know if it is illegal. I suspect it isn't, as long as they don't zero it out. But do they mark it "unclaimed" after a certain time? I don't know.

Fern

 

[laxmom]

Medical billing software just isn't written to allow that to happen. In our office, the person that enters that info does not have check writing priveleges and I know that would not be the case with offices that use outside billing companies. We tried outside billing because it was cheaper than having to pay benefits and salary to an individual in house. The number of mistakes went thru the roof!! We brought it back in house.

In our state, the time frame for unclaimed funds is something like 2 years. I will also add that you, Fern, are a minority. You know what your benefits are, you check your EOB's and keep track of your account. Out of our entire patient base, I have not one patient that follows all three of those patterns! Most people want that done for them or trust the insurance company to do it right. Those days are done and most don't realize it.

 

[Mimi39]

Anyone who is on Medicare with original Medicare or an Advantage HMO or PPO who is having this type of problem should call their state SHIP office for help in straightening it out. Here in PA it is called the Apprise program.

 

[Icarus]

Medical billing software just isn't written to allow that to happen.

The medical group I use does exactly what Fern described in both parts of her list. I get statements showing what I paid, what's been paid by insurance, what's been written off, what's been submitted to the insurance company but not paid yet and what my balance or credit amount is. The medical group and my doctor are preferred providers in the group I use, so they accept the contracted amount for a service as the full payment (less the 10% co-payment and deductibles.)

So, there is software available that does just that.

Also, I don't pay co-payments or deductibles up front.

My dentist, on the other hand, won't take assignment from my dental insurance (Met Life), which has always bothered me. I keep thinking about finding a different dentist, but never seem to get around to doing it. The dental insurance and their schedule of usual and customary charges is actually very good compared to what this dentist actually charges. If the dentist was willing to do it, he could submit a treatment plan to Met Life and the would tell them up front exactly what part of it will be covered and how much will be paid. Many dentists do that for major work.

-David

 

[Kal]

My dentist does it different. I have to pay the whole bill at time of service; they immediately (while I am in the office) submit the claim electronically to my insurance company; who then mails me a check which I usually receive in 2 - 3 weeks. Pretty efficient, but of course I have to have the money to pay up front

George

Wow! I'd drop that dentist in a heartbeat. One option would be to pay with a credit card. That way you get a 30-day delay in payment, plus the dentist gets hit with a 3-6% fee for the credit card charge. Use an AMEX card and the fee is the highest of any.

My dentist offers the option to pay at the time of service and if I do, I get a 5% discount.

 

[John Cummings]

I have NO co-pays for anything so I never have to deal with that problem

 

[laxmom]

So, there is software available that does just that.

-David

There is different software for different specialties. We have used both that work for us and neither shows this information. We have patients that come in so often that we would be mailing a book every month if our statements showed all that information.

 

[Icarus]

There is different software for different specialties. We have used both that work for us and neither shows this information. We have patients that come in so often that we would be mailing a book every month if our statements showed all that information.

The office I visit is part of a large medical group, and they send out statements as needed that show whatever detail is necessary on the statements.

The only reason I replied is because you said that such software wasn't available. It clearly is available, and in my opinion, it's probably illegal to keep overpayments over a certain period of time. I don't believe there's only two software packages available for medical practices, specialty or not.

When a medical office selects a software package, they should be evaluating all the features available. If dealing with overpayments and reconciling patient account balances is an important feature to that office, then they will select a package that offers those features. Apparently, that wasn't an important feature for the office you work in.

-David

 

[laxmom]

Sorry you don't believe me, David. But for us, this is true. I have no reason to lie about it. Nothing for me to gain. I would agree and would have considered it had I had any say in the choice. Unfortunately, like most businesses, the people who make those calls aren't the people that the decision affects.

 

[Kay H]

I went to my ophthomologist last week for the 1st time in 2 yrs. I had an outstanding balance of $3.??. I asked what it was for. The receptionist said that is what my insurance didn't pay from my last visit. I told her I don't remember getting a bill for that amt. She said they don't dend bills for blances undwer a certain amt (I forget the amt). I wonder if I had changed Drs, if I would have been billed.

All my other docs don't hesitate to send a bill for current balances.