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Obfuscating insurance cards.

Collecting copays and deductibles is essential in today's tight healthcare environment. Collecting what is owed at the time of service is critical. Your office should carefully monitor the changes in your patients' insurance cards.

One significant change that we have seen involves the way in which provider time-of-service information is displayed on patients' insurance cards. In the past, insurance cards had provider information with clear-cut designations, such as PCP (primary care physician) copay: $10; Spec (specialist) copay: $25; ER (emergency room) copay: $75. Some newer cards now have provider information notes that are not nearly as straightforward or easy to understand (figure).

Provider relations representatives for plans whose cards are depicted in the figure explained some of their designations as follows:

* Card #1: The patient is to pay the specialty provider 30% of the coinsurance amount--after the deductible has been met--for the service provided on the day seen. When asked to give a coinsurance amount so that the provider might collect the correct amount, the provider relations representative advised that until the claim had been received and processed, it would not be possible to advise the correct amount to request. This of course, makes it virtually impossible to accurately collect a copay at the time of service.

* Card #2: We asked whether the "office service 1 to 3" designation applies to visits to specialists only or to all doctor visits. Provider relations explained: "The basis of your collection depends on the number of any and all physician visits to date. In other words, if the patient has only had 2 doctor visits in his or her insurance calendar year, the office is to collect a $30 copay for the day. If the patient has seen 4 or more physicians, then the office is to collect 30% of the patient's coinsurance amount for the day's visit after the deductible has been met. We were advised that if the provider wishes to know what the coinsurance amount is or needs the patient's deductible information, the provider "should call the patient's benefits department to obtain that answer or go online for the current status of the patient account."

* Card #3: This card does not inform the provider what to collect if the visit is a consultation (99241-99245). The provider relations representative again advised it was impossible to know what was owed until the claim was processed, but that the amount paid would be based upon coinsurance and deductible. We were advised that it would not be inappropriate to collect "some copay" but that the amount collected is left to "provider discretion" Therefore, as with Card #1, it is virtually impossible for the provider to know what to collect at the time of service.

It is critical to cash flow to collect copays at the time of service and, in fact, it is a contractual obligation for the provider. However, the lack of clarity on patients' insurance cards makes collection processes very difficult. It might be helpful to proactively contact carriers prior to the patient visits in order to have some guidelines to effectively collect at the time of service.

Steven F. Isenberg, MD

Dr. Isenberg is an otolaryngologist in private practice in Indianapolis;
Figure. These exaruples show how the provider information
that appears on todays insurance cards can vary and how
complicated it can be. * no specialty designated; PCP =
primary care physician; Spec = specialist; ER = emergency

Card #1           Card #2                           Card #3

PCP copay   $15   Office service 1-3 copay *   $30  Dr. visit copay $15
Spec copay  30%   Office service 4+ copay *    30%  (CPT codes 99210-15,
ER copay:   $75   ER copay                     30%  99211-15)
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Author:Isenberg, Steven F.
Publication:Ear, Nose and Throat Journal
Geographic Code:1U3IN
Date:Apr 1, 2009
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