Health Care Providers’ Challenge—Risks of Copay Waivers, Discounts

For health care providers that are out-of-network with a patient’s insurance, navigating reimbursement is a tactical imperative. The current economic environment makes it more difficult for patients to pay coinsurance, while insurers are increasingly motivated to cut expenses.

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Creative billing solutions, such as reducing a patient’s copay may seem attractive and provide more predictability for patients and providers. But large insurers like Aetna, Cigna, and UnitedHealthcare have labeled some discounting tactics as “fictitious billing” and have initiated or brought counterclaims in nearly 20 lawsuits against ambulatory surgery centers nationwide, alleging fraud and seeking damages.

Outcomes have been mixed, requiring providers to carefully consider their programs to manage billing for out-of-network claims.

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