Co-pay or no co-pay? That is the confusing question

Preventive care -- a long list of services including mammograms, childhood vaccines and tobacco cessation counseling -- for patients covered by private insurance is, in most cases, supposed to be covered without co-pays or coinsurance, thanks to the Patient Protection and Affordable Care Act.

The new rules apply to policies that took effect after Sept. 23, 2010. But some physicians and their patients find that, rather than smoothing out the preventive care process, the new regulations only worsen the confusion about whether a co-pay or coinsurance is due. Often, neither the patient nor anyone in the office knows the new rules.

Stephen Meyers, MD, is a family physician with Eagle Physicians, a large multisite, multispecialty group in Oak Ridge, N.C. He also writes a blog and maintains a Twitter stream and Facebook page as MedSavingsDoc, offering tips on how to save on health care.

The opportunity to provide preventive care with no out-of-pocket contribution might seem like a boon to his practice and a major topic for him online, but that hasn't been the case.

He makes it a habit to ask the 100 patients he sees each week why they're seeing him. "Usually it's something like, 'My wife sent me,' " he said. Thus far, not a single one has mentioned receiving preventive care without having to pay anything out of pocket.

"It amazes me," Dr. Meyers said. "It's like nothing occurred."

He said he felt his practice didn't get much outside help with figuring out the new rules. And his feeling isn't the only sign that the rules aren't catching on the way they were meant to.

Experts say physician practices will have to spend time contacting payers to figure out circumstances in which co-pays are due, and in some cases refunding money they have collected in error.

But, they say, taking the time to collect a co-pay at the right time could pay off. Patients will come for preventive care visits, and staff can be clear about when to collect that $20 or $30 co-pay, saving time and money having to chase it down.

Preventive care fine print

Physicians, health plans and consumer advocates hailed the new rules as a way to promote prevention and cut down on chronic illness. But so far, the reality has been mixed at best, as few patients seem to be either aware of the benefit or able to take advantage of it. Physicians also are confused about when to collect a co-pay, leaving some practices with refunds due to patients and others short on cash they could have collected rightfully.

"Some physicians don't even know the change occurred," said Cheryl Gregg Fahrenholz, a practice management consultant whose company, Preferred Healthcare Solutions, is based in Bellbrook, Ohio. She said physicians traditionally rely on their staffs to know when to collect co-pays -- but they're not sure, either.

Part of the problem is that the rules allow for exceptions. Insurers may charge a co-pay for a preventive visit under a few circumstances:

• When the patient is enrolled in a "grandfathered" plan not subject to the health system reform law's mandates. A grandfathered plan is one that has made no changes to its benefits and thus is not subject to regulation under the health reform law.
• If the physician is out-of-network for the patient's plan.
• If services for another problem are provided during the same visit. This last exception has proven the most problematic, as the AMA predicted in a Sept. 17, 2010, letter to federal officials offering comments on the new regulations.

In its letter, the AMA warned federal officials that the rules as written might not take into account the "practical realities of how patients typically obtain preventive services."

The AMA advocated for the government to amend the rules so that a co-pay would never be required if the visit included a covered preventive care service, because most patients come to see their physician expecting to address both preventive care and acute problems during the same visit.

Preventive care ideal meets reality

The dilemma, as the AMA letter stated, is "if a physician performs a preventive medicine examination and a problem is identified, the physician must either handle the problem without compensation or require the patient to schedule another appointment to address the identified problem."

Instead, the AMA letter continued, insurers should absorb the difference. Health plans "must be required to assume the financial obligations of the cost-sharing requirements for preventive services which were previously the responsibility of the patient, rather than shift those responsibilities to physicians." Insurers should be prohibited from bundling those acute services into other preventive services.

Dr. Meyers said that even before the new rules, private payer policy made this very common. It presents an awkward choice for the physician: Ask the patient to return for another visit, or forgo compensation for care.

"It sometimes is a very delicate conversation," Dr. Meyers said. "It doesn't make sense to patients for you to say, 'You're here for this preventive visit, and I understand you have this problem, but I can't render that today. Either you'll be charged a co-pay you didn't expect, or I won't get paid.' Patients are not very sympathetic to that."

The AMA noted that insurers already commonly fail to recognize CPT modifier -25, which is used when a physician discovers and treats a problem during a visit for preventive care, or a different condition.

The AMA proposed amending the rules so that insurers must follow CPT coding conventions and recognize modifiers where they indicate that both preventive services and a specific separate problem were addressed during a single visit.

For now, however, the rules stand as they were laid out in the July 19, 2010, notice.

Knowing when to collect

Fahrenholz suggested a relatively low-tech solution to the dilemma of when to ask for a patient's out-of-pocket share: Use a spreadsheet.

She advised looking at the list of preventive services that are supposed to be covered under the new rule, pulling the ones most common for the practice -- covered vaccinations for a pediatric practice, for example -- and posting a list of those services at the reception desk where patients check in and out.

Those practices using an integrated electronic medical record and practice management system might be able to program in a prompt that will ask the person entering the patient's information a series of questions, then determine if a co-pay is due.

Either way, she said, both clinical and front-desk staff need to know the rules so they can determine when a problem treated during a preventive visit means that a patient who didn't originally owe a co-pay now owes one.

Susan Gliatis, practice management consultant for Central Ohio Practice Management in Columbus, Ohio, said sometimes there will be no way to avoid making a phone call to a patient's plan for clarification about what is covered. That will be needed if the plan has not alerted physicians and patients as to what preventive care does not require a co-pay.

Practice management experts stress that it is important to refund even a $10 co-pay if it's collected in error. It's acceptable to credit an account, but only for a patient seen on a regular basis who gives the practice permission to apply the co-pay amount to a balance or to his or her next visit.

In general, a practice has 30 days to refund money collected in error, Fahrenholz said.

What to tell patients

Cindy Dunn, RN, a principal with the Medical Group Management Assn.'s Health Care Consulting Group, recommended keeping patients informed in whatever way is practical, including posting details about the covered services on the practice's website.

Practices should educate patients so they understand the new rules, she said. "There is going to be confusion, and I'm sure there will be refunds made."

She acknowledged that it can be awkward to tell a patient that preventive care will be covered without a co-pay but that if a problem pops up, they could be on the hook for $20 or $30. But that's exactly what she recommended. "Tell them, 'Hey, this is a preventive visit, so we can do a physical, but we can't address acute problems.' "

Fahrenholz said it's not necessary to "reinvent the wheel" when trying to get patients the correct information about the new rules. She advised visiting the Medicare or CMS websites for fact sheets that outline when preventive care should be available without any out-of-pocket expense.

Every practice should have a financial policy, and that can be amended to reflect the changes and alert patients to when they can expect to write a check and what will happen if they are owed a refund.

Gliatis said educating patients about preventive care coverage is a way to take advantage of a positive element of health system reform.

"They don't realize -- this is trying to make you healthier," she said. "I would advise people, 'Understand what your policy covers. Every year, make a list of what's covered, or call up your insurance company and ask because it does change. Make yourself aware as a consumer.' "

Gliatis and Fahrenholz said the best possible physician response to the new rules is to use them to get patients in for preventive care. Fahrenholz recommended sending postcards to patients informing them of the change in the law (along with important exceptions), and inviting them to make an appointment for recommended preventive care. Without some type of notification, patients do not know what their coverage is, and that risks lost revenue for the practice, she said.