Understanding of Copay in Medical Billing

Posted by Niurka Moreno on July 31st, 2015

Copay – A very important healthcare term that everyone should learn before consulting a Provider. For patients, Copay is defined as a fixed amount that they are responsible to pay out-of-pocket during every visit to a Provider or Hospital. On the other hand, for Providers and Healthcare Facilities, it is revenue generated from patients on a regular basis. This revenue is an add-on to the reimbursements that Providers make from Payers for the clinical services rendered. Thus, Copay has a very important role to play in the lives of patients as well as Providers. Let us learn more about Copay and what effect it has on medical billing and collections:

What is Copay?

To split the healthcare costs and to avoid unnecessary visits to Providers/Hospitals by members, Payers came up with a policy called Copay, which will determine a fixed amount that patients have to pay during each visit to a Provider or Hospital. The amount is determined by the Payer based on a patient’s health insurance plan and not by the Provider. The insurance company will pay the medical bill expenses as per allowed amount (Covered under the plan), once the Copay is paid by the patient. No matter if patients meet their fiscal year deductible or not, Copays are mandatory to be paid at each Provider or Hospital visit.

Copay varies from one insurance policy to another and is determined based on several factors like the type of insurance plan and the type of Provider (Primary care or Specialist) a patient chooses. Medical billing and collections will be better for Providers, if they attend to more patients with higher Copay plans. But this is not fully under the Providers’ control.

Things to Note for Providers:

• As Copay's contribute a great value to the overall revenue generated by Providers, it is important that they keep a tab on it properly and account it in the Billing software.

• For unaffected cash flow, every Provider must do patient eligibility verification before providing healthcare services.

• Healthcare eligibility verification will check for patients’ Deductible, Copay, Co-insurance and how long the insurance plan is valid. This way Providers can eliminate claim denials and improve cash flow.

• Most importantly, patient eligibility verification helps identify whether a Provider is in-network or out-of-network for that particular patient’s plan. It is the duty of Providers to explain how much their patients will owe, once the services are rendered. The finances should be discussed before providing the services, so that the patients will have time to decide.

• Copays differ from Primary care to Specialty care services. Therefore, Providers must perform Healthcare eligibility verification to learn what a patient’s Copay is.

As mentioned above, patient eligibility verification plays a vital role in determining Copay. Therefore, Providers can get help from reputed medical billing outsourcing companies to perform professional Healthcare eligibility verification services.

About MGSI:

MGSI is one such experienced medical billing outsourcing company that has 21 years of experience in providing exceptional medical billing and collections to its clients. Based in Florida, this highly-renowned national, medical billing outsourcing company provides patient eligibility verification services for healthier cash flow.To learn more details, log on to www.mgsionline.com.