Can you waive a co-payment?
By Deborah Green, Esq.

I have a small family practice in a lower-income neighborhood. Many of my patients ask that I waive their co-payment because “all the other doctors do it.” Can I do this? Can I just ask these patients to give me a hardship affidavit?

If you waive the co-pay, you are defrauding the insurance company. The agreement made among you, your patient, and the insurance company says that you will collect a certain amount from the patient for services rendered by you to the patient and the insurance company will pay the balance.

Often, 20 percent of your customary bill is paid by the patient and 80 percent is paid by the insurance company. If the bill is $100, the patient is required to pay you $20 and the insurance company is required to pay you $80.

If you routinely waive the co-pay, then your customary charge for the service is $80 (because that is, in effect, the amount you are charging for the service). Therefore, the insurance company would owe you only $64 per visit. The insurance company would be entitled to revisit the bills submitted by you and deduct the overpayments.

A wholesale acceptance of hardship affidavits is also unacceptable. The doctor is required to independently ascertain that the patient is in fact indigent as claimed. Insurance companies would certainly look askance at your billings if you claimed that a substantial number of your patients could not afford to pay the co-pay.

Ask your patient to bring you an affidavit from a clergy person or another respected member of the community confirming indigence.

I am about to enter into a capitated contract with a managed care organization. Are there any specific areas I should investigate?

Get information concerning population characteristics, utilization history by CPT code, and cost of treating the patient population.

Review the population’s utilization history by CPT code. Do not enter into an agreement until the plan gives you this information. If the plan refuses you may be able to get a copy of it from your state insurance department, since most state insurance departments require plans to file this type of information with them as does the National Committee for Quality Assurance.

Direct questions to Deborah Green, Esq., at healthattorney@aol.com or call 954-971-7778. Ms. Green is licensed to practice law in New York and Florida. Her specialty is healthcare.

DISCLAIMER: This column is provided for educational purposes only. The information presented is not presented as legal advice with respect to any matter and no attorney-client relationship is established.