Multiple Co-Pay Charges for a single visit?

[kmass]

What is the name of your state (only U.S. law)? California

What are the provisions for a doctor charging the insurance company multiple co-pays for one visit? I'm not sure if this qualifies as fraud or not...

At a recent visit to an Urgent Care Clinic, I noticed my co-pay amount was for three visits, I asked about it and was told that because there were multiple diagnosis, the clinic needed to charge for multiple co-pays. Does this seem right? It is my understanding; one visit; one charge. Not, one visit and if we diagnose 3 separate issues then we will bill the insurance company for three visits.

 

[ajkroy]

What is the name of your state (only U.S. law)? California

What are the provisions for a doctor charging the insurance company multiple co-pays for one visit? I'm not sure if this qualifies as fraud or not...

At a recent visit to an Urgent Care Clinic, I noticed my co-pay amount was for three visits, I asked about it and was told that because there were multiple diagnosis, the clinic needed to charge for multiple co-pays. Does this seem right? It is my understanding; one visit; one charge. Not, one visit and if we diagnose 3 separate issues then we will bill the insurance company for three visits.

You are correct. The copay is actually tied to the E&M code (Evaluation and Management), the level of which is determined by the complexity of the presenting issue/s. If your copay is a flat fee per visit, then you only pay that once for that visit. The office can be reimbursed for a higher-level of visit (which means more money from the insurance company) if they have the proper documentation. If a procedure was performed for one of the other diagnoses, they can use modifiers and bill that, too. Still only one copay, though. An office cannot charge a different E&M code for each dianosis; they can increase the level of the code instead.

For example, let's say I go to the doctor because of a cough. While examining me, he sees a suspicious lesion on my back and offers to take it off right there in the exam room. The office can bill an E&M code for the office visit AND a surgery code for the lesion. But because the copay is only tied to the E&M code, only one copay is required.

This advice differs if your copay is a percentage of the bill and also depends on whether the clinic was in network and part of your plan.

 

[ecmst12]

Check with your insurance company to be sure, but it definitely sounds fishy to me.