Copay vs coinsurance

The distinction matters for your patient collections workflow. Copays are predictable and should be collected at the point of service. Coinsurance amounts depend on the allowed amount and cannot be precisely calculated until the claim is adjudicated, which means they are often billed after the fact. Point-of-service collection rates for coinsurance are lower than for copays because the amount is not known at check-in.

Your payer mix determines your overall patient responsibility exposure. High-deductible health plans (HDHPs) have replaced traditional copay plans in much of the commercial market. Under HDHPs, patients owe the full allowed amount until the deductible is met, which makes patient collections look more like consumer collections than traditional copay collection. Practices that have not updated their patient financial counseling and collections processes for HDHP prevalence are experiencing rising patient bad debt.

Deductible status at the time of service is a key eligibility check. Collecting a $30 copay from a patient who has not yet met their $2,500 deductible is an undercollection. A proper eligibility verification process checks deductible status and estimates patient responsibility at the time of scheduling so collections expectations can be set before the visit.