A patient arrives for a scheduled appointment and presents an insurance card that includes a specified $20 co-pay for specialist visits. However, the patient states that they have met their annual out-of-pocket maximum and should not be charged. What is the appropriate action for the medical assistant to take?
Refuse service unless the co-pay is paid upfront regardless of the patient's out-of-pocket expenses for the year.
Insist the patient pays the co-pay as indicated on the insurance card, disregarding the patient's claim.
Verify the patient's insurance benefits to determine if the co-pay is required.
Do not charge the co-pay and allow the patient to see the specialist, taking the patient's word at face value.
The correct action is to verify the patient's insurance benefits to confirm whether the annual out-of-pocket maximum has indeed been met. If so, the co-pay would not be required. Simply accepting the patient's word without verification could lead to improper billing procedures. Charging the co-pay without verification might result in an overpayment and unnecessary administrative work to issue a refund. Denying the patient service based on non-payment of the co-pay without verification could breach the patient-practitioner agreement and potentially result in patient dissatisfaction or a formal complaint.
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