Deductibles, Co-pays & Co-insurance: Info you need to know

Deductibles Are Too High

The recent increase in deductibles and co-pays has negatively affected many patients and practices. If you’re out-of-network, do you have to collect the full deductible? Is it possible to waive a portion of the co-insurance? Should you lower your fees to improve patient compliance?

Let’s Discuss Fees

Let’s begin by discussing fees. There are 3 factors that usually determine a fee:

  • the work and skills utilized by the provider,
  • the provider’s overhead/administrative costs, and
  • the malpractice expense of the provider.

You should select your fees based on a combination of the following:

  • your clinic location
  • the local Medicare fee schedule
  • in-network fee schedules
  • out-of-network rates
  • what other DCs, PTs and MDs charge in your town
  • what you feel most comfortable with – remember, you can’t sell what you don’t own.

Can I Just Have One Fee?

Is it possible to have “one fee” across the board for every man, woman and child that walks into your office?

No. It’s practically impossible to do that in today’s healthcare world. Many offices have a combination of standard (regular) fees, managed care fees (ASH, Optum, Multiplan, OrthoNet), mandated fees (Medicare, Medicaid), workers’ compensation fees, personal injury fees, TOS fees, pre-pay plans, hardship fees, DMPO fees (ChiroHealthUSA) and on and on.

Dual Fee Schedules

Being part of all or some of the above does not mean you have a dual fee schedule. This was told to me by Dr. Foxworth at ChiroHealthUSA and it makes a lot of sense. Having a dual fee schedule is inappropriate. Make sure all patients are aware of your “regular” fees. Some providers give discounts without advising patients of the regular fees. This could cause unnecessary confusion if a cash patient returns as an insurance patient (sticker shock).

Now, more than ever, patients need to be educated on what their insurance company pays for – it’s not only about patient education anymore. The doctor or CA/PTA must address the difference between medically necessary/insurance reimbursable care vs. maintenance care with the patient on the initial visit and on every re-exam. Patients need to understand that they may not be able to use ALL their visits. It’s not okay for patients to get upset at the front desk CA/PTA or billing manager because the patient’s insurance benefits stink.

Now back to co-pays, deductibles and co-insurance. These amounts vary and could be difficult to manage – you could have 30 patients come in with 15-20 different patient financial arrangements.

Make The Attempt

Most insurance carriers require healthcare providers to attempt to collect any unpaid portion of the deductible, co-pay and co-insurance. According to Medicare, routine waiver of deductibles, co-pay and co-insurance is inappropriate because it results in false claims, violations of the anti-kickback statute, and excessive utilization of the services and items that get paid.

A carrier may consider a provider to be misstating the actual charge. For example, the provider charges $100, but routinely waives the co-insurance (20% / $20) – then the actual charge is $80. The Federal government may exclude healthcare providers from participation in Federal healthcare programs for violating certain statutes.

Financial Hardship

However, certain conditions may permit a healthcare provider to waive (partially or fully) the collection of these amounts. One of the conditions is financial hardship. The U.S. Department of Health and Human Services provides information on how to create a discounted fee schedule. Send an email to if you’d like to receive a copy of this document.

We have recently seen a few insurance carriers request to see proof that the patient paid some or all of their co-pay, deductible and/or co-insurance. Clear policies and procedures are very important for those who take insurance to be able to discuss with patients. Good policies allow patients to understand your office insurance billing and collections procedures. Patients should understand that collecting money from insurance companies is not that easy. Good policies allow patients to understand that they are responsible for a portion of the bill and can help you avoid providing care for which you will never be paid.

Get a Compliance Manual

How would you feel if you got a letter from an insurance carrier or state board today asking to see your coding and billing compliance manual? Get comfortable and compliant with your billing policies and get your staff trained on collecting the money the right way. Ask us about our Billing & Coding compliance manuals. Our program only takes two weeks to implement and it’s really affordable – only $795 – and if you follow us on Instagram (MeyerDCAligned or MeyerPTAligned), we’ll help you get $100 off.

For more info on products mentioned in this article or for info on current product specials, please contact your personal MeyerPT Account Manager.

If you don’t know who your Account Manager is, please call 866.528.2144 to find out.

Recommended Products from PT Aligned