I have read and agreed to the following statements regarding copays, deductibles regarding my insurance policy. By signing below, I understand that I am responsible for all fees and costs related to my insurance plan.
Every effort is given to provide accurate information regarding copays and/or deductibles prior
to your visit. We provide the information given to us by your health plan and are notified of the below disclosure each time.
UNLESS OTHERWISE REQUIRED BY STATE LAW, THIS NOTICE IS NOT A GUARANTEE OF PAYMENT. BENEFITS ARE SUBJECT TO ALL CONTRACT LIMITS AND THE MEMBER'S STATUS ON THE DATE OF SERVICE. ACCUMULATED AMOUNTS SUCH AS DEDUCTIBLE MAY CHANGE AS ADDITIONAL CLAIMS ARE PROCESSED.
While we take every effort to provide accurate information to you it is your responsibility to
know and understand your insurance policy and fees associated with it prior to your visit.
As claims are processed if additional patient responsibility is listed you will receive an invoice
from our office, as well as an explanation of benefits from your insurance company.
Routine Copay/Deductible Waiver Violates The Law
It is not illegal to write off a patient’s copay/deductible balance if the provider makes a good-faith attempt to collect. However, when a provider has a policy of not attempting to collect copays/deductible that becomes illegal. Health and Human Services, Office of Inspector General, identified several suspect behaviors that indicate illegal routine copay/deductible waiver:
Advertisements that state that Medicare will be accepted as payment in full.
Advertisements that promise discounts to Medicare beneficiaries.
Routine use of financial hardship forms without attempt to determine patient’s
Collection of copayments only where patient has supplemental insurance that
pays for copays.
Charging more to Medicare beneficiaries to
offset the waiver of coinsurance.
Sham insurance programs that offer to cover copays but have insignificant
In a recent federal court case, a provider sued Cigna for failing to pay out-of-network claims. Cigna then countersued the provider for potential injunctive relief under certain ERISA laws, and the court found there was merit for the countersuit, so Cigna was able to attempt to obtain damages for unjust enrichment and intentional tortious interference with contractual relations
The Employee Retirement Income Security Act (ERISA) is a broad set of
federal laws that govern health insurance (among other things).The injunction would be filed to stop the provider from discounting the services based on the “in” vs. “out” of network
Commercial insurance providers have contracts (i.e., legally binding
agreements) to provide health insurance to employers and employees—and now, under the
Affordable Care Act, to individuals as well.Commercial insurance providers charge a premium for that health insurance. The employer, employee, and/or individual pays that premium.
The health insurance contract establishes mutually agreed-upon deductible and copayment amounts for both in-network and out-of-network providers.
Typically, the contract also establishes a financial incentive for beneficiaries to use in-network providers as well as a financial disincentive to use out-of-network providers.
Because this is a contract—which, again, is a legally binding agreement with an employer or individual—if a provider comes along and decides to unilaterally waive patient deductibles and copays, then the provider is reducing the covered person’s contractual financial obligation.
So, by waiving deductibles and copays, the provider is interfering with the employer’s and/or individual’s contract with the insurance carrier—and that puts the provider at risk of being sued for damages.