Cigna Waiving Copays

Posted : admin On 1/29/2022

Health insurers, Cigna and Humana, are waiving all out-of-pocket costs for coronavirus treatments nationwide. 'Two of the country's largest health insurers, Humana and Cigna, are. Waiving copays, deductibles and coinsurance for physician services. Cigna is waiving all cost-sharing for in-network medical or behavioral telehealth visits for customers in the U.S. A copay (or copayment) is a flat fee that you pay on the spot each time you go to your doctor or fill a prescription. For example, if you hurt your back and go see your doctor, or you need a refill of your child's asthma medicine, the amount you pay for that visit or medicine is your copay.

AMARILLO, TX – DME suppliers are facing a common challenge. Commercial insurers are closing their provider panels, thereby not allowing the suppliers to bill the insurers as in-network suppliers. This relegates the out-of-network suppliers to one of two choices: 1) decline to serve the patient or 2) to serve the patient and bill the insurer as an out-of-network supplier.

The challenge with billing as an out-of-network supplier is that the patient normally has to pay a higher copayment than if the DME supplier was an in-network supplier. This has led some out-of-network suppliers to offer to waive the patient’s copayment if the patient purchases from the out-of-network supplier. The problem with waiving such copayments is that the out-of-network supplier may be setting itself up for liability.

Private parties, including insurers and competitors, often file lawsuits against out-of-network health care providers that routinely waive copayments and deductibles. For example, Aetna has pursued an aggressive legal campaign against out-of-network providers that waive copayments and deductibles.

Aetna has brought suits against providers in California, New Jersey, New York, and Texas. Similarly, other insurers have brought suit against out-of-network providers who waive copayments and deductibles. Many of these suits allege breach of contract claims and unjust enrichment. Allegations of fraud and deceptive trade practices are also common.

Claims of statutory and common law fraud allege that providers who waive copayments submit claims that do not reflect the actual discounted charge and, therefore, materially misrepresent the transaction. As an example, such claims have succeeded in the federal and state courts of New Jersey. In other states, regulatory authorities have issued guidance indicating that routine waivers of patients’ cost-sharing obligations constitute fraud.

As evidenced by the suits brought by various private parties, a DME supplier will be at risk of having to defend a lawsuit for steering patients to an out-of-network supplier and waiving copayments.

A number of state and federal courts have addressed cases involving out-of-network providers that routinely waived copayments and deductibles. A common claim in these cases is that the provider submits a false or fraudulent claim and overcharges the insurer when the provider bills the insurer the full amount but does not intend to collect the copayment.

Cigna waiving copays for therapy

Upon reviewing case law, several legal scholars have concluded that the non-collection of the patient’s copayment or deductible may be lawful in and of itself, but the intentional or contractual waiver of the obligation to pay the deficiency prior to submitting a claim is, by contrast, unlawful.

An example of a case ruling in favor of the insurer is Kennedy v. Connecticut General Life Insurance Co., 924 F.2d 698 (7th Cir. 1991). In Kennedy, a chiropractor sued CIGNA because CIGNA refused to pay a claim submitted by the chiropractor who was an out-of-network provider. Under CIGNA’s insurance policy, CIGNA covered 80 percent of medical expenses and the beneficiary was required to pay the remaining 20 percent.

When the chiropractor submitted a claim of $1,727, CIGNA suspected that he did not collect the 20 percent copayment. Therefore, CIGNA requested proof that the $1,727 represented 80 percent of the full amount charged. In the process, CIGNA received information that the chiropractor waived the patient’s copayment. As a result, CIGNA refused to pay the claim and the chiropractor sued. The court ruled in favor of CIGNA. According to the court, if the chiropractor “wishes to receive payment under a plan that requires co-payments, then he must collect those co-payments – or at least leave the patient legally responsible for them.”

Another case is Feiler v. New Jersey Dental Association, 467 A.2d 276 (N.J. Super. Ct. Ch. Div. 1983). In Feiler, a dental association sought an injunction against the billing practices of Dr. Melvin Feiler who waived copayments for 97 percent of his patients. Moreover, Dr. Feiler advertised that he would waive copayments. The association claimed that Dr. Feiler’s activities were fraudulent and constituted unfair competition. The court agreed and ordered that Dr. Feiler either bill insurers for the amounts he actually collected or inform insurers of any waivers provided to patients.

A number of state insurance agencies have weighed in on this issue. For example, the New York Department of Insurance has taken the position that the practice of waiving copayments may constitute fraud in the state:

Depending on the circumstances, the waiver of otherwise applicable co-payments could constitute insurance fraud.

If a health care provider, as a general business practice, waives otherwise required co-insurance requirements, that provider may be guilty of insurance fraud. See opinion of the Office of General Counsel dated March 27, 2008. For example, if a health care provider indicates that the charge for a procedure is $100 and the insurer anticipates that the provider will collect a 20% co-payment amount, the insurer will reimburse the insured $80. If, however, the provider waives the co-payment, that provider’s actual charge becomes $80, which then obligates the insurer, assuming payment at 80% of the usual charge, to reimburse the insured only $64.

Waiving

See N.Y. Ins. Dep’t, Position Statement, “Re: Health Insurance, Waiver of Deductibles and Co-Insurance” (April 2, 2008).

In the event a DME supplier accepts the risks associated with waiving copayments for out-of-network patients, then it would be prudent for the out-of-network supplier to notify the insurer that the supplier waived the patient’s cost-sharing responsibility. Such notice may serve as a credible defense against any claim of fraud and deceptive trade practices. However, such notice may cause the insurer to deny the claim.

Baird
will be presenting at Medtrade Spring 2014 in Las Vegas, where he will
share his expertise, advice, and ideas. CLICK HERE to register for
Medtrade Spring, held from March 10-12, 2014, at the Mandalay Bay
Convention Center, Las Vegas. – See more at:
https://medtrade.com/news/manufacturer-provider/Utilization-of-a-Mar-1749.shtml?utm_source=Silverpop&utm_medium=email&utm_campaign=44879209&utm_term=8333315&utm_content=#sthash.Zb6CL7KX.dpuf

Baird will be presenting at Medtrade Spring 2014 in Las Vegas, where he will share his expertise, advice, and ideas. CLICK HERE to register for Medtrade Spring, held from March 10-12, 2014, at the Mandalay Bay Convention Center, Las Vegas.

Jeffrey S. Baird, Esq, is Chairman of the Health Care Group at Brown & Fortunato PC, a law firm based in Amarillo, Tex. He represents DME suppliers, pharmacies, infusion companies, and other health care providers throughout the United States. Mr. Baird is Board Certified in Health Law by the Texas Board of Legal Specialization and can be reached at (806) 345-6320 or [email protected]

This story also ran on NPR. This story can be republished for free (details).

Karen Taylor had been coughing for weeks when she decided to see a doctor in early April. COVID-19 cases had just exceeded 5,000 in Texas, where she lives.

Cigna, her health insurer, said it would waive out-of-pocket costs for “telehealth” patients seeking coronavirus screening through video conferences. So Taylor, a sales manager, talked with her physician on an internet video call.

The doctor’s office charged her $70. She protested. But “they said, ‘No, it goes toward your deductible and you’ve got to pay the whole $70,’” she said.

Don't Miss A Story

Subscribe to KHN’s free Weekly Edition newsletter.

Cigna waiving copays for telehealth

Policymakers and insurers across the country say they are eliminating copayments, deductibles and other barriers to telemedicine for patients confined at home who need a doctor for any reason.

“We are encouraging people to use telemedicine,” New York Gov. Andrew Cuomo said last month after ordering insurers to eliminate copays, typically collected at the time of a doctor visit, for telehealth visits.

But in a fragmented health system — which encompasses dozens of insurers, 50 state regulators and thousands of independent doctor practices ― the shift to cost-free telemedicine for patients is going far less smoothly than the speeches and press releases suggest. In some cases, doctors are billing for telephone calls that used to be free.

Patients say doctors and insurers are charging them upfront for video appointments and phone calls, not just copays but sometimes the entire cost of the visit, even if it’s covered by insurance.

Despite what politicians have promised, insurers said they were not able to immediately eliminate telehealth copays for millions of members who carry their cards but receive coverage through self-insured employers. Executives at telehealth organizations say insurers have been slow to update their software and policies.

“A lot of the insurers who said that they’re not going to charge copayments for telemedicine ― they haven’t implemented that,” said George Favvas, CEO of Circle Medical, a San Francisco company that delivers family medicine and other primary care via livestream. “That’s starting to hit us right now.”

One problem is that insurers have waived copays and other telehealth cost sharing for in-network doctors only. Another is that Blue Cross Blue Shield, Aetna, Cigna, UnitedHealthcare and other carriers promoting telehealth have little power to change telemedicine benefits for self-insured employers whose claims they process.

Such plans cover more than 100 million Americans — more than the number of beneficiaries covered by the Medicare program for seniors or by Medicaid for low-income families. All four insurance giants say improved telehealth benefits don’t necessarily apply to such coverage. Nor can governors or state insurance regulators force those plans, which are regulated federally, to upgrade telehealth coverage.

“Many employer plans are eliminating cost sharing” now that federal regulators have eased the rules for certain kinds of plans to improve telehealth benefits, said Brian Marcotte, CEO of the Business Group on Health, a coalition of very large, mostly self-insured employers.

Cigna Waiving Copays

For many doctors, business and billings have plunged because of the coronavirus shutdown. New rules notwithstanding, many practices may be eager to collect telehealth revenue immediately from patients rather than wait for insurance companies to pay, said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

“A lot of providers may not have agreements in place with the plans that they work with to deliver services via telemedicine,” she said. “So these providers are protecting themselves upfront by either asking for full payment or by getting the copayment.”

David DeKeyser, a marketing strategist in Brooklyn, New York, sought a physician’s advice via video after coming in contact with someone who attended an event where coronavirus was detected. The office charged the whole visit — $280, not just the copay ― to his debit card without notifying him.

Cigna Copay Price

“It happened to be payday for me,” he said. A week earlier and the charge could have caused a bank overdraft, he said. An email exchange got the bill reversed, he said.

With wider acceptance, telehealth calls have suddenly become an important and lucrative potential source of physician revenue. Medicare and some commercial insurers have said they will pay the same rate for video calls as for office visits.

Some doctors are charging for phone calls once considered an incidental and non-billable part of a previous office visit. Blue Cross plans in Massachusetts, Wyoming, Alabama and North Carolina are paying for phoned-in patient visits, according to America’s Health Insurance Plans, a lobbying group.

“A lot of carriers wouldn’t reimburse telephonic encounters” in the past, Corlette said.

Catherine Parisian, a professor in North Carolina, said what seemed like a routine follow-up call with her specialist last month became a telehealth consultation with an $80 copay.

“What would have been treated as a phone call, they now bill as telemedicine,” she said. “The physician would not call me without billing me.” She protested the charge and said she has not been billed yet.

By many accounts, the number of doctor encounters via video has soared since the Department of Health and Human Services said in mid-March that it would take “unprecedented steps to expand Americans’ access to telehealth services.”

Medicare expanded benefits to pay for most telemedicine nationwide instead of just for patients in rural areas and other limited circumstances, HHS said. The program has also temporarily dropped a ban on doctors waiving copays and other patient cost sharing. Such waivers might have been considered violations of federal anti-kickback laws.

At the same time, the CARES Act, passed by Congress last month to address the COVID-19 emergency, allows private, high-deductible health insurance to make an exception for telehealth in patient cost sharing. Such plans can now pay for video doctor visits even if patients haven’t met the deductible.

Dozens of private health insurers listed by AHIP say they have eliminated copays and other cost sharing for telemedicine. Cigna, however, has waived out-of-pocket costs only for telehealth associated with COVID-19 screening. Cigna did not respond to requests for comment.

Cigna waiving copays for therapy

Teladoc Health, a large, publicly traded telemedicine company, said its volume has doubled to 20,000 medical visits a day since early March. Its stock price has nearly doubled, too, since Jan. 1.

With such a sharp increase, it’s not surprising that insurers and physicians are struggling to keep up, said Circle Medical CEO Favvas.

“It’s going to be an imperfect process for a while,” he said. “It’s understandable given that things are moving so quickly.”

Abbie VanSickle, a California journalist, wanted her baby’s scheduled wellness visit done remotely because she worried about visiting a medical office during a pandemic. Her insurer, UnitedHealthcare, would not pay for it, the pediatrician told her. Mom and baby had to come in.

“It seems like such an unnecessary risk to take,” VanSickle said. “If we can’t do wellness visits, we’re surely not alone.”

A UnitedHealthcare spokesperson said that there was a misunderstanding and that the baby’s remote visit would be covered without a copay.

Jacklyn Grace Lacey, a New York City medical anthropologist, had a similar problem. She had to renew a prescription a few weeks after Cuomo ordered insurers to waive patient cost sharing for telehealth appointments.

Is Uhc Waiving Copays

The doctor’s office told her she needed to come in for a visit or book a telemedicine appointment. The video visit came with an “administrative fee” of $50 that she would have had to pay upfront, she said — five times what the copay would have been for an in-person session.

Cigna Copay Amounts

“I was not going to go into a doctor’s office and potentially expose people just to get a refill on my monthly medication,” she said.