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Does a Doctor's office HAVE TO charge you the co-pay

On Lawyer & Legal » Insurance Law

14,336 words with 12 Comments; publish: Thu, 17 Dec 2009 16:54:00 GMT; (80078.13, « »)

The state is: ? Va

Mine didn't, for almost 3 years. I worked for her as a nanny and also for a few months as a parttime receptionist. When I would offer to pay my co-pay at the time of services rendered, she would say, don't worry about it.

When I quit, she mailed me my final pay stub attached to a letter saying that she applied my pay to my past due account (all my co-pays over the time I worked for her!) and is demanding payment for the balance. Lastly, she informed that her practice does engage an agency for their collections practices and my balance may be turned over to them, "witch" (I think she meant "which") may affect my credit. DOES A DOCTOR'S OFFICE HAVE TO CHARGE YOU THE INSURANCE POLICY CO-PAY, or can they pick and choose who they charge? I've already sent in a complaint to the Dept. of Health Professionals' Enforcement Division, but was just wondering if anyone knows.

The state is: ?

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  • 12 Comments
    • Insurance companies frown on doctors waiving the copay, but it does happen sometimes.

      However, in your case, the doctor is ALLOWED to charge you the copay. While doing it the way she did was unprofessional and vindictive, you were required to pay the money all along.

      It may have been illegal for her to withhold your final pay though. Contact your state DOL regarding that.

      #1; Thu, 17 Dec 2009 19:55:00 GMT
    • Quote:
      === Original Words ===

      DOES A DOCTOR'S OFFICE HAVE TO CHARGE YOU THE INSURANCE POLICY CO-PAY, or can they pick and choose who they charge?
      First, thank you for editing your post to include the above question. You did it AFTER my post... and BEFORE the whiny little crap-head started pissing and moaning.

      Second, as already answered by several RESPONSIBLE members, the doctor has NO obligation to charge you the co-pay. And yes, they can bill you later for the co-pay charges that were 'overlooked' (purpose or not).

      #2; Sat, 19 Dec 2009 14:49:00 GMT
    • My previous posts have disappeared. It appears there are some skirts to hide behind. I don't think they're my momma's.

      In many states and circuts, like California and the ninth, a doctor does have to charge the co-pay. Delta Dental seems the big litigator on this issue. It is a contractual issue between the provider and the insurance company. If the provider also increased the amount billed to the insurance company based on not getting the co-pay it can also be a crime. The CA attorney general is currently not in accord with many CA courts nor the courts with each other. Although the cases I saw are a little old, as is the AGs opinion.

      I don't know the law in VA, perhaps one of the senior members who actually have the ability to search case law can give a citation to a provider's ability to waive the co-pay and not have VA courts think it fraudulent or a routine waiver as deceptive or in violation of the insurance contract?

      Since it is not unheard of for a doctor to accept insurance alone, especially if state law allows him to waive co-payment, if a doctor does in fact seem to do so for years there is a contractual concept called waiver which could apply. The repeated failure to enforce his rights may limit his ability to enforce that at this time. There is also a concept called laches. It's like the Statute of Limitation, but is more of a fairness issue when a person (like the doctor) sleeps on his rights. Since that only applies if the OP changes his position (like only went to this doctor or went more times than they thought otherwise best) and if any lawsuit asks for an equitable remedy, waiver is the more likely defense if sued.

      It is also clear the pay for work is different from the payment to the doctor for services. He cannot dock the OP's paycheck to pay the accounts receivable.

      The end result is no matter the law, the answer is fuzzy. What is happening at all and what the doctor's right to demand payment is is dependent on specific state law and the facts rather then general legal principles--beyond the fact the paycheck cannot be used to pay the debt without the OP's agreement.

      #3; Sun, 20 Dec 2009 01:34:00 GMT
    • Again a post is removed. Moderator, interesting. I believe the above post is legally incorrect. It certainly is in California and the Ninth circut and suspect it is in VA as well although I don't have the ability to search case law as easily there. I believe a doctor is generally obligated by contract and, depending on other facts, by statute to collect the co-pay. The answer is not always clear and different courts have different holdings. But, even with Google as the only resource, I can find many cases related to this.

      I think both are also legally incomplete in that they don't offer the OP any defense. I think there are potential defenses. I admit we can't know if they can be successful without all the facts and those facts cannot be developed over the internet in this forum.

      #4; Sun, 20 Dec 2009 09:47:00 GMT
    • Quote:
      === Original Words ===

      Again a post is removed. Moderator, I believe the above post is legally incorrect. It certainly is in California and the Ninth circut and suspect it is in VA as well although I don't have the ability to search case law as easily there.

      I think both are also legally incomplete in that they don't offer the OP any defense. I think there are potential defenses. I admit we can't know if they can be successful without all the facts and those facts cannot be developed over the internet in this forum.

      If you'll stop arguing, she will stop removing. Really easy-to-follow instructions.
      #5; Sun, 20 Dec 2009 09:50:00 GMT
    • Sheesh, thank you for quoting what I wrote. I'd love a message from someone stating how that violated the terms of service.

      Anyway, for the 9th circut's opinion on if a doctor can choose to not charge a co-pay, read the discussion at:

      FindLaw | Cases and Codes

      The case is not "on point", but points to the legal issues and some of the case law regarding it.

      For a California discussion on the requirements to collect, see:

      http://www.betterobin.com/OkToWaive.html

      Please don't post "But, it's not VA law!" unless you have some citation to VA law. States differ, as do circuts, but, unless there is some statutory regulation specifically different, they do tend to be similar.

      #6; Sun, 20 Dec 2009 13:24:00 GMT
    • So it is your opinion that a case from a completely different state/circuit that is not even on point, is binding on the poster/the poster's doctor?

      FYI, CA law DOES tend to be different than the law of most other states. So unless you have a VA law that applies, I think you are the one that needs to stop posting.

      #7; Sun, 20 Dec 2009 13:32:00 GMT
    • The point is, whether the doctor is REQUIRED to charge the copay or not is not relevent to this situation. OP really wants to know if the doctor is ALLOWED to charge her now, after first saying she was NOT going to charge. And the answer is still yes.

      Most PCPs make more money from copays then they do from insurance payments. If they were to stop collecting copays, they wouldn't be able to stay in business.

      #8; Sun, 20 Dec 2009 14:44:00 GMT
    • All I have is persuasive opinion from an APPELLATE court. The other side has.....NOTHING. Who needs to stop posting? Please. Let's have those who feel it is permissive for a doctor do decide if they want to charge the copay or not give a statute, article, case or ANYTHING to support their OPINION.

      Otherwise, spend your time writing to someone who cares.

      As to the more reasonable "allowed" issue, that has been addressed in a couple of deleted posts. The defense is Waiver or laches. Look them up, educate yourself. Or, ask the moderator to repost that which was deleted; seemingly to protect the error of some senior members for my Google theory on the matter.

      (Again, I await senior member beat down.)

      #9; Sun, 20 Dec 2009 14:52:00 GMT
    • Quote:
      So it is your opinion that a case from a completely different state/circuit that is not even on point, is binding on the poster/the poster's doctor?
      No, it is my opinion that an appellate court decision is persuasive on other circuits and states and, absent contrary statute, court decision or any other controlling or persuasive authority should be followed.

      Quote:
      The point is, whether the doctor is REQUIRED to charge the copay or not is not relevent to this situation. OP really wants to know if the doctor is ALLOWED to charge her now, after first saying she was NOT going to charge. And the answer is still yes.
      If a person is "allowed" a legal right under contract, but does not enforce it, repeatedly, for three years, is there a defense to the eventual enforcement?

      Yes. It's called waiver. For some claims, depending on the facts, it could also be called laches.

      Quote:
      Most PCPs make more money from copays then they do from insurance payments. If they were to stop collecting copays, they wouldn't be able to stay in business.
      Yes. But, when you look at the studies and literature, may don't for a couple of reasons. One is they may charge more for the service to the insurance company. In other words, they price themselves less, in order to get more patients, and charge a bit more to the insurance. In many cases, this is insurance fraud. However, this is something many insurance companies litigate. So, while your premise is probably true, we KNOW insurance companies think this is a problem with providers. So, what is your point?

      Also, there is a relationship with the OP. IF the doctor is merely ALLOWED and not REQUIRED, then waiver and laches become a far more valid defense.

      #10; Sun, 20 Dec 2009 17:59:00 GMT
    • I'm still waiting for any of those who want me to stop posting to come up with ANY actual research of VA law. But, while we wait....let's see what the AMA and Federal law say on the matter.

      From AMA report of the council and judicial affairs regarding professional courtesy and the collection of copay's at:

      http://www.ama-assn.org/ama1/pub/upload/mm/369/2a04.pdf

      Quote:
      E-6.13 Professional Courtesy

      Professional courtesy refers to the provision of medical care to physician colleagues or their families

      free of charge or at a reduced rate. While professional courtesy is a long-standing tradition in the

      medical profession, it is not an ethical requirement. Physicians should use their own judgment in

      deciding whether to waive or reduce their fees when treating fellow physicians or their families.

      Physicians should be aware that accepting insurance payments while waiving patient co-payments

      may violate Opinion 6.12. (II, IV) Issued June 1994.

      For federal law, I have no idea if true, but in a Surgical Assistant overview (Illinois) on the topic at:

      http://surgicalassistantresource.org/web_documents/surgical-assistant-overview.pdf

      Read with interest from page 16 to 21. The author feels not charging a copay while billing the insurance company violates HIPAA Section 242

      (Public Law 104-191 104th Congress) Title II, Subtitle E. Saying:

      Quote:
      Fraudulent & False Statements

       Professional courtesy discounts in the form of a

      waiver of a co-payment or deductible constitutes

      both health care fraud and false statements.

       Knowing you are required to collect a co-pay or

      deductible but billing insurance only is committing

      health care fraud;

       By billing an insurance company one charge but

      failing to collect the patient co-pay or deductible, the

      provider is making a false statement regarding the

      charge.

      He also lists an OIG fraud alert:

      Quote:
      What Does OIG Say?

      In 1991 the Office of Inspector General (OIG) issued a

      fraud alert concerning the wavier of co-pays and

      deductibles. The OIG stated that billing insurance

      only may violate the False Claims Act, the Anti-

      Kickback Statute, the Civil Monetary Penalties Law,

      42 U.S.C sec 1320a-7a(a)(5), as amended by Pub.L.No

      104-91 sec 231 (h), and State laws.

      Although, later, when the insurer was Medicare or Medicaid, the author lists some reasons for how the OIG says the copay can be waived.
      #11; Mon, 21 Dec 2009 10:32:00 GMT
    • Quote:
      Yes. But, when you look at the studies and literature, may don't for a couple of reasons. One is they may charge more for the service to the insurance company. In other words, they price themselves less, in order to get more patients, and charge a bit more to the insurance. In many cases, this is insurance fraud. However, this is something many insurance companies litigate. So, while your premise is probably true, we KNOW insurance companies think this is a problem with providers.
      Cite those "studies and literature" please.

      Physicians have ONE fee schedule. Physicians who contract with certain insurance companies must accept that insurance company's payment (plus any co-pay or co-insurance) amount as payment in full. Many times those insurance companies reduce the Physician's regular fees by more than half.

      Oh and BTW....the AMA is a political organization that only approximate 2 % of the actual practicing Physicians belong to. They suggest guidelines.

      Medicare/Medicaid are federally run and whole 'nuther story. Physicians are not permitted to courtesy Medicare/Medicaid co payments.

      #12; Mon, 21 Dec 2009 10:45:00 GMT