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:

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.

How to Determine How Much You're Owed

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.

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Comments 11 comments

Bilaras profile image

Bilaras 6 years ago from Earth

That's interesting information. Thanks for sharing.


Deni Edwards profile image

Deni Edwards 6 years ago from california Author

You're welcome.


Camille Clark 5 years ago

My psychiatrist has kept over $300 in a credit to my account and I desparately need the money and can't get him to sign a check for me because he is 25 miles from his office here in San Antonio


Deni Edwards profile image

Deni Edwards 5 years ago from california Author

If you have insurance, call your insurance company and let them know that you are having difficulty receiving your money. The insurance company should make a phone call to the office.

You need to call and request this check. His office can do it and send it to you in the mail. If they give you any grief, inform them that you will file a complaint with the BBB. Also, there are state boards that you can file a complaint with, as well. If you let me know what state you are in, I can look up the info, and leave another comment for you.


emily 5 years ago

My surgeon is charging me $30 for my post op visits. I told them my prior sign included 90 day global. They say everytime I walk in the door and see a doctor or nurse I must pay the specialist copay. I called the ins. company and they can't find any wording in my policy stating whether a copay should be collected or not. I feel I am over s barrel. They have no incentive to limit my post op visits. $30 to see someone for 5 min is outrageous. What can I do? This is the first time I have experienced this.


Deni Edwards profile image

Deni Edwards 5 years ago from california Author

You need to call your insurance company back. Speak with the customer service representative (I would recommend a supervisor), and let them know what is going on. This isn't something that is worded in your policy. This is just the way it is. You spoke with someone who doesn't know what they are doing.

Give the CSR or supervisor the dates of service that you were seen. Ask how the claim was processed. They will say that there was no payment because the visit was during the global period or post-op. This means, also, that you are not responsible for a copayment. If there is no amount owed, you can't be charged. Inform your insurance company that you are routinely charged $30.00 for these post-ops, and ask for a conference call with the office for help obtaining your refund.

If you still have a problem, please contact me through HubPages, and I can help you.


Lisette 4 years ago

Before my surgical procedure my Dr required me to come in for a "pre-op" visit and it was basically the same exact thing as the visit before. I wasn't asked for a copayment then and now the Dr.'s office is saying I owe them money for the co-pay for that day....is this legal??


Deni Edwards profile image

Deni Edwards 4 years ago from california Author

I wouldn't go so far as to say it is illegal--it is unethical, however.

I would suggest that you pull out the EOB from your insurance company. If you don't have one, call your insurance company and ask if the claim for that service date has been processed. Ask how much you owe. If/when they tell you that you don't owe anything, ask the rep to call your doctor's office, as they are trying to collect from you.

If there isn't a bill/claim on file with your insurance company, inform your doctor's office that they need to submit the bill before you will pay, as you don't believe you have a copayment for pre-op visits.

Lastly, make sure that it is a pre-op visit they are trying to collect--not a copay for the surgery itself.


lillypad33206 4 years ago

I paid my doctor $1,000.00 toward my surgery months ago. They were paid by blue shield but won't refund my money.

Blue shield only paid for one medical code and I owe $98.00 out of the grand paid for that code but blue shield didn't approve the other codes billed. My doctor is appealing it but blue shield said it is illegal for them to hold my money since that is all they approved right now. Is this true? My doctor says it isn't and that I have to wait until those other codes are paid before they will refund my money. Blue shield says that they are in a contract and that according to the contract they are in I am not liable. If they won the appeal then I of course would have to pay 30% and they should bill me then but not keep my money. Is this true? Is blue shield right that it is not legal for them to do this? My doctor says he needs to contact his attorney because he has never heard of this before and his attorney is gone until late next week. Thanks


Deni Edwards profile image

Deni Edwards 4 years ago from california Author

Lillypad,

Blue Shield is correct. The doctor's office should not have taken your money, first of all, and secondly, the doctor's office needs to refund your money.

Since the doctor is contracted with Blue Shield, the doctor is only allowed to bill you for how much money Blue Shield states that you are responsible for. If the doctor has any problems with the payment, the office needs to go after Blue Shield, not you.

Your physician is telling a lie, unfortunately. If he/she is a contracted provider, the physician knows full well that he is unable to bill patients for more than what the insurance company indicates the patient owes.

I would be curious to know the codes that were billed. Often times, surgeries result with unexpected other problems that were not known until the patient is opened up, and these are easy to appeal and receive payment. Other times, these other codes are, indeed, not payable, because the extra code is part of the main procedure--it's like billing for the incision, the surgical instruments and the surgical procedure--that can't be done, because the cut and the instruments are part of the main surgical procedure.

I would call Blue Shield back and ask them to do a conference call with the physician since he refuses to give your money back. The physician is stealing your money.


lucy 4 years ago

When posting patient payments there are some question that you need to ask if you were not given a procedure for posting patient payments.EX; if a patient mails a check that is an overpayment on the patient's account what is the procedure

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