Routine Waivers of Copays and Deductibles Amounts

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While the occasional waiver of copayment obligations is permissible, the routine waiver of copay and deductible amounts is not. The federal Anti-Kickback Statute (AKS) prohibits the renumeration to a beneficiary of a federal and state health plans by any person or entity if the person or entity knows (or should know) that the renumeration is likely to influence the beneficiary to obtain services/items from that particular person/entity.

 

In addition to the to the prohibition from the AKS, some states also prohibit routine waivers of commercial payer copayments and deductibles. It is also highly likely that contracts with commercial payers would stipulate that a provider is obligated to collect copay and deductible amounts from their members. If this requirement is ignored, it would be a breach of contract and can lead to termination by the payer. Furthermore, some payers have claimed (and have won) that the waiver of the collection of the copay/deductible is insurance fraud since the provider is misrepresenting its actual charge.

A provider may forgive the copayment/deductible amount in consideration of a particular patient’s financial hardship. This hardship exception may not be used routinely, however. The current federal poverty guidelines and financial information from the patient are often used for hardship determination. We highly recommend having a policy in place to ensure consistent, non-discriminatory, and well-documented processes.

Physician Revenue Navigators is a premier company that provides revenue management for healthcare entities. Contact us to learn more about how we can help you navigate through healthcare regulations.

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