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Routine Forgiveness of Co-Payments

- Published by the American Medical Billing Association

Routine forgiveness or waiver of copayments may constitute fraud under state and federal law. Where the insurance contract requires a doctor to make reasonable attempts to collect the patient's portion, an open question surrounds the definition of "reasonable attempts to collect the debt." Historically, doctors could satisfy the requirement by sending at least three letters attempting to collect the debt. However, the Office of Inspector General (OIG) has taken the position that the routine waiver of copayments could constitute a criminal kickback in Medicare cases. This has emboldened private insurers, who are relying upon this contractual provision as a basis for a post-payment recoupment audit. If a provider cannot demonstrate efforts to collect from the patient, the carrier may demand a refund for any benefits paid. http://www.physicianspractice.com/blog/forgiving-patient-copays-can-lead-unforgiving-consequences?GUID=9533E9BE-E642-4774-9B8C-7106375F772C&rememberme=1&ts=17122013
Look for payers to conduct more post payment reviews for opportunities to take-back money where copays and deductibles have not been collected.