CNC: Co-payment Collection

Most member's health coverage includes a co-payment, a deductible amount and/or co-insurance. It is very important that you verify the exact amount of the member's co-payment and/or deductible/co-insurance prior to providing any services to the member.

When a patient comes into your office, it is very important that you call to verify benefits and eligibility on the patient and ask the insurance plan specifically about services prior to rendering the services. If there are services that are non-covered, you must have the patient sign a Patient Waiver for Non-Covered Services prior to the services being rendered.

CNC POLICY:

No money can be collected at the time of service other than any applicable co-payments, deductibles and/or co-insurance. Some plans only require a co-payment, while others may have a deductible and co-insurance. Always ask whether the member’s plan has a co-payment, co-insurance or deductible when verifying benefits.

If you do not collect the appropriate co-pay, co-insurance and/or deductible, when you receive your Explanation of Benefit(EOB) or Notification of Payment(NOP), you may bill the patient for any co-payment, deductible or co-insurance 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 a 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.

CNC Provider’s may not bill the member for the discounted or disallowed amount for covered services rendered to any member of a CNC 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, co-payment or co-insurance amounts for covered services.

Waiving Co-payments, Deductibles and Co-insurance

CNC POLICY:
CNC providers cannot waive, reduce or discount any co-payments, deductibles, or co-insurances. This includes accepting a "lower" co-payment amount than the amount indicated on the member's subscriber ID card, discounting co-payments and/or waiving co-payments including services deemed “professional courtesy” and TWIP (take what insurance pays).

Absent true financial hardship (with complete, current, supporting, documented evidence of such hardship maintained in the patient’s health record, please see below), the full amount of the co-payment as well as ALL co-payments, deductibles and co-insurance due and owed must be collected by all network providers for every patient visit.

For CNC Contracts:
Failure to consistently comply for individuals covered by a CNC contracted payor is in violation of the policies of our contracted payors and may result in the termination of your status as a CNC participating provider.

For Medicare:
Failure to comply for individuals covered by Medicare is a violation of the Federal False Claims Act, Federal Anti-Kickback Statute, and the Federal and State Insurance Fraud Laws. Failure to comply 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 CNC contracts, no money can be collected at the time of service unless there is a co-payment and/or deductible amount stated on the ID card. Some plans only require a co-payment, while others may have a deductible and co-insurance. Always ask whether the member’s plan has a co-payment or deductible when verifying benefits. Remember, you cannot waive or reduce co-pays!

If you did not collect the member's co-payment, deductible or co-insurance at the time of service, once you receive your Explanation of Payment, you may bill the member for any co-payment, deductible or co-insurance up to the plan’s allowed amount.

True Financial Hardship

If a patient has a financial hardship, there are possible steps to take to assist them, other than waiving the

co-payment, deductible, and/or co-insurance. 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. Standards for waiving co-pays, deductibles, and/or co-insurance that indicate that only objective, reasonable criteria are consistently utilized for every patient presenting with a financial hardship.

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.

Please review our sample template Financial Hardship Policy and Confidential Financial Worksheet.