Understanding Copayments: Have You Overpaid?

Not all doctor visits require co-payments, yet some physician’s offices will routinely collect them, resulting in a credit balance on an account. Often, people enter a physician’s office and immediately pay their co-payment. Depending on the amount of a patient’s co-payment, this can result in several hundred dollars owed to a patient.

If you are billed for your doctor’s visits, you might think that you don’t have any money owed to you, because a credit is not reflected on your bill. This is not the way it works. Because you are receiving a bill that has been generated for a specific date, the bill will not reflect your entire account balance.

You should always keep your receipts and compare them to your insurance company's explanation of benefits.  If you don't understand the explanation of benefits, you should call your insurance company and ask.  Also, it's always a good idea to call your insurance company and find out how much your copayment is before you receive any physician services.

The most common circumstance for credit balances occurs when a patient has had a surgery, no matter how minor. Outlined below is how to determine if you have a refund owed to you from being overcharged for surgical procedures, and how to obtain your refund.

 

Surgeries, or invasive procedures, range from small to large. The most common smaller procedures, usually performed by a family practitioner, include ingrown toenail removals, a mole removal with or without a biopsy, or stitches from an injury.

The larger procedures are performed by specialists, like cardiologists and orthopedic surgeons, and normally include a pre-operative visit.

Procedures of both scales have a global period, commonly referred to as post-operative care or follow-up days. The doctor visits that fall into post-operative care are not payable by the insurance company or by the patient.

Every insurance company has a list of procedures and a pre-determined number of global days that are included with the payment of the procedure; the number of global days is taken into consideration when the insurance company pays the doctor for the procedure.

Small Procedures:

There is normally a global period of 7-10 days for small procedures. Your co-pay should be collected the day the procedure is performed. A follow-up appointment should be scheduled at that time.

The second visit involves removing any stitches that were required for the procedure and to ensure there is no infection. This visit is not payable by the insurance company or by the patient.

Large Procedures:

The global period for larger procedures commonly range from 30-120 days. In order to determine the exact amount of global days, a phone call to your insurance company may be necessary.

The first opportunity at overpaying your doctor for the larger procedures is the day of the pre-operative visit. There should be no charge for this visit unless you have not paid your co-pay for the surgery.

Each and every visit that falls into the global period does not require a co-payment. The only exception to this rule is if you are seeing your doctor for a reason unrelated to the surgery.

Also, if your surgery requires a cast, the visits for removal and recasting are not payable.

If you have paid your physician’s office a co-payment under the above-listed circumstances, chances are good that you have a credit balance. Hopefully, you have kept all of your receipts, and maybe even the EOBs (explanation of benefits) from your insurance company. This will allow you to reconcile your account. If you haven’t, there is still a way to get the money owed to you.

Reconciliation:

Even though there is no payment expected, the post-operative visits should still be billed to the insurance company as a record that you were seen. This also enables the insurance company to review their payment methodology for surgeries.

You should have received an EOB from your insurance company reflecting that no payment was issued and the reason: included into post-operative care; or something similar.

If payment was issued to your doctor, they may have accidentally billed for the wrong service. The procedure code that should have been used for the postoperative visit is 99024 and not a code that begins with ‘992’. If the procedure code, or service, begins with ‘992’, you need to call your insurance company and let them know your visit was a post-op visit and billed as a regular office visit.

You should attach all of your receipts to your EOBs and take them to your physician’s office or call them. Sometimes a physician employs a billing service, in which case you will need to call them. If you feel uncomfortable doing this, or it proves to be difficult, you should call your insurance company and ask for assistance.

No Receipts:

If you haven’t kept your receipts from the physician’s office, you can ask them to review your account for a credit balance. If they quickly respond by saying your balance doesn’t reflect a credit, they haven’t done what you have asked them to do. You can still show a balance on your account and still be owed a refund. Here’s why:

All the services that are provided by your doctor’s office are listed in an itemized format by the date of service, and what you have requested them to do is review every date of service, or more specifically, the period of time around your surgery.

If you have a balance on your account there are two reasons (besides you owing them money):

1. They are still waiting to receive payments from your insurance company.

Even though you have paid your copayments for each visit, your doctor might not have received the payment from your insurance company. Because there is a visit that remains unpaid, there is a balance on your account.

As an example, you might be owed $80.00, but because they are waiting for payment from a service that cost $150.00, there will not be a credit reflected on your account.

2. They have not applied a write off or adjustment.

The doctor’s office has a fee schedule—a list of charges for every service. Often, payment calculations vary among insurance companies. The fee schedule will reflect the highest reimbursement so the doctor isn’t underpaid.

For example, one insurance company might pay a percentage of billed charges. Another insurance company might pay a pre-negotiated amount. If the doctor bills $300.00 and the negotiated rate is $350.00, the doctor is only going to receive up to what has been billed.

When payment is received from an insurance company, an adjustment, or deduction, needs to be applied to the remaining balance to close it out. Often, an account will reflect a balance because these adjustments have not been applied.

As you can see, determining if you are owed a refund requires more than a quick glance at the total balance. Instead of looking at just the account balance, a review of your entire account needs to take place. If you believe this has not occurred, you can either ask for a printout of your account history or call your insurance company and explain you believe you’re owed a refund and have misplaced your receipts. Your insurance company will either call them or request an itemized account history from your doctor’s office or billing service. You can ask your insurance company to forward a copy to you.

Sometimes a doctor’s office might tell you that there will be a charge for giving you a copy of your account history. This is an illegitimate charge, and you should call your insurance company. There is no reason that they should charge you for this. The reason you are requesting the information is because you believe that they have made an error.

A billing service is unlikely to charge you a fee for this information. The last thing they want is for you to complain to the doctor’s office about them. They do not want to jeopardize their employment.

Hopefully, your doctor’s office is adhering to insurance billing guidelines as it pertains to surgeries. If not, whether done intentionally or accidentally, you should have a better understanding of how to determine if you are owed money and how to get it refunded.