e-MDs Billing Tip: Maximize Patient Collections- Pt 2 Coinsurance

e-MDs Billing

e-MDs Billing Tip: Maximizing Patient Collections In Primary Care- Part 2 Coinsurance

Copays, Coinsurance, and Deductibles.  These are the three basic means of front end revenue that practices should be collecting before a patient is seen by a provider.  We’re going to define those terms, let you know what your front desk team should be doing to collect those on a daily basis and why they are crucial to your bottom line. Today’s topic will be Coinsurance.

Coinsurance:  This form of payment requires the patient (insured) to pay a percentage of the cost of a healthcare service and the insurance company pays the remaining percentage based on the provider’s contracted rate.  We’ll use the same example from Part 1 of this series.  This time instead of paying a copay the patient has a 20% coinsurance.

Total Billed $85.00
Contractual Adjustment -$18.00
Allowed $57.00
Patient Coinsurance (20%) $11.40
Pmnt from Ins. Co $45.60


Here we see that insurance has a significantly higher percentage of the claim than the patient does at 80%.  Unlike, copays which are fixed no matter the level of care, coinsurance amount are based directly on the CPT codes used during the visit (99213 versus 99215).  Therefore, coinsurances are a bit more difficult to collect up front than copays.  The front desk person doesn’t know what level of care the provider will carry out.  Solor recommends collecting the coinsurance percentage on the card for the LOWEST level of care usually offered for that set of symptoms.  So for coughs and colds, most providers would have a minimum level 3 E&M code.

If the front desk person has a cheat sheet (we call them “job aides”) at their desk of the allowed amounts for the 5-7 biggest insurers, they can feel very confident in collecting SOMETHING before the patient is seen.  Once the patient leaves the room, the provider can communicate via sticky note, taskman, etc. what the level was to the front desk person.  They can collect anything additional that is required at check out before the patient leaves.

Of course, this will all depend on your office work flow.  The goal is to collect the correct percentage for the correct service rendered BEFORE the patient leaves.

One other thing to keep in mind, patients can have both a copay and coinsurance depending on the policy.  They might have a $40.00 copay for primary care and 20% for any procedures done outside the scope of a “normal” office visit.  Every policy is written differently, so pay attention to those EOBs when they come back and make notes for future visits.  As a rule, coinsurance amounts do not go toward a patient’s deductible but do count toward their out of pocket max.

If you have questions about this blog or have other questions about billing workflow, let us know if we can be of assistance to your practice by filling out the form below.

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Solor is a specialized third party medical billing company for e-MDs® Practices.  e-MDs® is a registered trademark of e-MDs Inc.  e-MDs Inc. is not affiliated with Solor, Inc., our products, services, or website.  Additional legal disclaimer here:  http://wp.me/P7cvJE-kI

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