Q. I have a question about what often happens when I am contracted with both the primary and secondary insurers for a particular patient.
After filing a claim with the primary insurance company, my office then submits a claim to the secondary insurer for the patient-responsibility portion of the charges (e.g., a 20-percent coinsurance, a deductible, or a copay).
In many instances, the secondary payer's explanation of benefits (EOB) will show a zero payment to me, with a zero patient responsibility. And, according to the secondary EOB, I cannot collect from the patient what the primary payer's EOB shows as the patient's responsibility.
Now, if I were NOT contracted with the secondary payer, I could bill the patient for the amount left unpaid by the insurance carriers because I have not agreed to the secondary payer's fee schedule. But when I AM contracted and bound by both primary and secondary contract agreements, I have to write off the patient's portion of the bill.
But if I write off the balance, and the patient pays nothing, aren't I violating statutes that say I am always required to collect copays and deductibles?
A. According to TMA's Office of General Counsel, to forego collecting a copayment or deductible does not violate the statutory prohibition against routine waiver of copays and deductibles because:
- You aren't waiving the copay (or deductible or coinsurance) as a marketing ploy or other inducement to increase business;
- You aren't causing an insurer to pay more than is due under its policy with your patient;
- When you submitted the claim, you placed the amount you usually charge in the appropriate field; and
- Since you are contractually bound by the secondary payer's hold harmless clause, your waiver is not routine but an intendedresult of the insurance code's hold harmless mandate. You've simply agreed to a fee schedule with the secondary insurer that happens to be less than the primary insurer's allowable.
As you stated, if you were not contracted with the secondary insurance company, there would be neither a promise to hold the enrollee harmless nor an agreement on a reduced fee, so you would be free to collect from the patient.
Content reviewed: 3/16/2007
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