1. Deductible - The amount the patient must pay for health care services each year before the patient's insurance begins to pay. These amounts may change every year.
2. CoPayment - The portion of the cost of an item or service that the patient is responsible to pay.
A practice that routinely waives the deductible or copayment amount is misrepresenting the actual charge. Routine waiver of deductibles and copayments by a practice is unlawful because it can result in false claims and excessive utilization of services. Routine waiver of deductibles and copayments may also violate the Medicare-Medicaid anti-kickback statute. Deductibles or copayment amounts may only be reduced or forgiven after consideration of a particular patient's financial hardship. A good faith effort must be made to collect deductibles and copayments, and exceptions to this policy must be well documented.
It is the policy of Sound Dental Care that copayment and deductible amounts that are the patient's responsibility under the rules of the Medicare program or any other governmental or commercial third- party payer and may not be waived, except on a case-by-case basis upon a determination of financial need. Prior to or at the time of delivery, the patient will be provided with an estimate of any amounts for which the patient is responsible for paying. Routine waiver of copayment and deductible amounts is a violation of federal law and practice policy.
Sound Dental Cares policy of limiting the patient’s out-of-pocket costs does not conflict with the requirement to collect deductibles and copays. Given the scope of the services that Sound Dental Care provides and the standard level of copayment or deductible required, it is extremely rare that a copayment or deductible would exceed our current maximum out-of-pocket cost of $189. It is important to note that if an insurance explanation of benefits instructs Sound Dental Care to bill for a deductible or a co-payment, we will do so.
Sound Dental Care will evaluate each account individually to determine financial hardships and any write-offs.