01/07/2021

Healthfirst-Reprocessed Claims Reflecting Double Copays

I have currently received multiple reprocessed claims from Healthfirst that are applying double and sometimes even higher copays to the patients and are taking money back from me. How do we know when double copays are applicable. Surely patients don’t know and will be resistant to pay them.

With the Health First Medicare Advantage plans, there are two categories of services that will apply a portion of the allowed amount to patient responsibility as their co-pay:

-Office visits, and

-Diagnostic testing, such as x-rays or low tech radiology services

To know when a patient may be subject to two co-pays, their benefits should be reviewed periodically to see what their responsibilities are for covered services, whether it be copays, coinsurance or deductible. As of 2021, there are four Health Plus Medicare Advantage plans that have an additional $15 co-pay for x-rays on top of their specialist co-pay for podiatry services:

-Signature HMO

-65 Plus Plan HMO

-Increased Benefits Plan HMO

-Coordinates Benefits Plan HMO

While a patient may be shocked to be billed for a second copay for diagnostic services, it is ultimately their responsibility to know what their plan covers and what they are financially responsible for with covered services. When Health First makes an adjustment and applies the different to a copay, the patient must be billed, and any grievance about the error in processing should be directed towards the HMO for not processing the claim correctly when it was initially submitted.