Business contracts

In Arizona I had medicaid. My physician co pay was $1. Here I have something similar but they call it medi-cal. I go to chir

Chiropractor here w $6 copay and even have secondary insurance. Secondary insurance does not require copay. $1 copay could be waived at drs discretion. Dr here says that his $6 copay to be waived is illegal. I think that he is very much lying. I know that it is illegal to waive copays w exception of medicaid. Is it true in CA? Also can dr legally charge full office visit cost when he knows u r on medic-cal/medicaid and force patient to sort out the insurance on his own, in an emergency?? Have heard conflicting statements on that one. Tyvm.

Nathan’s Answer

It can be waived, but on a very limited basis. What used to be a professional courtesy in the past is now under the ever sharpening eye of governmental pressure to ensure accountability. Can you prove further documented financial hardship? Otherwise, the doctor is looking at possible violations of the False Claims Act, the Anti-Kickback Statute (AKS) as well as a host of insurance fraud and other laws. The reason for this is say a procedure is allowed at $100 with Medicare or Medicaid (Medi-Cal in California) and the doctor is paid $80 with the patient paying $20. (80% standard) If the $20 is waived, the doctor should be getting reimbursed at $64 (80% of $80) not $80 (80% of $100). As a result, the doctor may have overcharged the government causing a situation where the government refuses to reimburse any the doctor on any further patient procedures pending civil (and possible criminal) investigations. As far as being forced to sort out the insurance on your own, if you are seeking care from a doctor who has opted out of Medi-Cal, you may be paying full fees if there is a private contract with a waiver. If the doctor participates in Medi-Cal, your rights for reimbursement will be stronger. However, this is on a case by case basis depending on the sort of treatment you are seeking.