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Texas

Is it legal for a doctor not to charge a copay or lower the copay for surgery and accept only what the insurance pays?

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2015-07-16 18:12:35
2015-07-16 18:12:35

You might really be asking two questions here.

1. Is it legal, as in can the provider find himself with criminal charges for doing it

2. Does the Insurance Company permit it? Could the provider lose his HMO or PPO contract?

  1. 1 Here's an answer from Minisota's Medicaid site

Clarification of DHS Copay Guidelines Providers cannot deny services to recipients unable to pay a copay. A provider must accept a recipient's assertion that he or she is unable to pay a copay and cannot require additional documentation of inability to pay. An unpaid copay is considered to be unpaid debt, and the provider is not required to continue to serve recipients with outstanding debt. If it is the provider's general practice to refuse to serve all individuals with outstanding debt, and the provider gives the recipient advance notice and a reasonable opportunity to pay the debt, and the recipient does not pay the copay(s) owed, the provider can then refuse to provide care. Recipients retain the ability to seek services from other enrolled MHCP providers. Providers may choose to continue to serve recipients who are unable to pay the copays. Note: If the recipient is unable to pay the copay, providers may accept payment of the copay on behalf of the recipient from another source.

http://www.dhs.state.mn.us/main/groups/business_partners/documents/pub/dhs_id_010456.hcsp

for more information see www.steveshorr.com

  1. 2 I've always been told that in an HMO or PPO the provider wasn't allowed to waive fees, but I haven't seen an actual contract or rule.

Even in the Minisota rules - it appears the provider cannot waive fees, except under special circumstances

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