Question

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Answer 1

Solution 1:

Coinsurance

Coinsurance is a fixed percentage that the insured has to pay against a claim after the deductible has been met. In health insurance, the insured is expected to pay a set amount at the time of service. Generally, coinsurance has an 80/20 split, the insured is responsible for 20% of the medical costs, and the insurer pays 80%. These terms are applicable after the insured has reached the insurance terms' out-of-pocket deductible amount. Copay plans are usually a fixed amount, making it easier for the insured to budget out-of-pocket costs. Copay plans help to predict medical expenses as the cost of care is spread over the entire year. With a copay policy, the insured is expected to pay at the time of each medical visit. With any insurance plan, patients have to make a copay when they visit the doctor.

What to do when the patient will not pay or cannot afford the copay.

• Doctor-patient relations: If a new patient does not want to or cannot afford to pay the copay, the doctor can decide not to see the patient. However, if the patient pays the first time but does not in the next visit, it becomes complicated. A lot of time and effort will have to be invested from the doctor or clinic's end to collect the payment. The doctor also has to consider that if he or she decides not to see the patient, it could be considered malpractice. Doctors make much investment to set up their practice, and failure to pay on the patient's part makes the struggle harder. However, it is also true that the physician's primary responsibility is to practice, support patients, and put patients first. Most doctors would be duty-bound to see a patient even if the patient cannot afford to pay. The only valid or justifiable reason for a clinic or doctor to waive the patient's copay is financial distress.

• Insurance company - clinic/doctor relation: The other important aspect to consider here is a relationship between the doctor's clinic and the insurance company. If a patient's insurance responsibilities are routinely waived, it could violate the clinic and insurance company's contract. If the clinic cannot establish that the patient's amount was collected or all attempts were made to collect it, the insurance company can demand a refund for reimbursement. The insurance company can also cancel the contract with the clinic and not allow services to the patients who have their policy. It is considered a felony to waive copays and deductibles for patients regularly. This waiver is considered a health care fraud as the clinic can claim wrong charges for their service. For example, if the patient's policy has a 20/80 split, then in a $100 amount, $20 has to be paid by the patient while $80 by the insurance company. However, if the copay was waived, then the patient's total bill effective is $80 and not $100.

• Thus, there are severe regulatory and legal issues that the healthcare provider has to consider in a patient copay waiver. These issues have compelled the US Department of Health and Human Services (HHS) to declare that it is illegal to waive copay or coinsurance regularly.

From the above analysis, we can see that there are ethical and legal considerations regarding a non-payment of copay or coinsurance.