My Client Can’t Afford Their Copay!

Dear Ryan,

I have been working in the field for several years, and I am finding that I am running into an issue. If my client tells me that they can’t afford their copay that week, I simply waive it. I believe in making sure care is accessible for my clients, and if I know that someone can’t afford it, I don’t want their copay being the barrier to care. Is this problematic? Other colleagues that I have consulted with have either said no, or they have told me that it might be but haven’t really told me why.


Compassionate Copay Waiver

Dear Compassionate,

Insurance copays and insurance reimbursements are such sticky areas to talk about, and they get even stickier when our clients’ finances come into play. The way I see it, you have a potential ethical issue, and a potential legal one. First, let’s talk about the legal one. If you work with a client who is using insurance in order to consume your services, you are contractually and legally obligated to collect co-insurance, whether that’s a deductible or a co-pay. Waiving copays and deductibles routinely is illegal. It’s a felony, and it violates both the Anti-Kickback Statute and the False Claims Act. The exception, it looks like, is if a client is going through a financial crisis of some kind, and then you might have precedent to waive copays until they get back on their feet. However (and this is a BIG however) – how do we determine what a financial crisis is? The law is the opposite of clear in what this determination means, and so if we can’t even get together on a definition of what a financial crisis is, how are we to determine whether or not our client is in one? And, there’s this whole concept of universality – if you would do it for this one client, are you going to use the same standard for all of your clients? If someone is going through a financial crisis and you waive copays, what if you have a client living in poverty but still owes a copay, or has a spend-down or a deductible that they have to meet? In other words, what if you have a client perpetually living in financial crisis? Legal precedent says that you can’t continually waive their copays, so what are you to do? It’s a slippery slope that, in my opinion, is best avoided.

This is a nice segue into the ethical precedent. There’s the whole universality of it all, but also, money is a part of the counseling relationship, unless you have a client who has no co-pay or deductible. Even if that was the case, if a client has a problem with their insurance, money comes into the equation REAL quick. That someone would come in and not be expected to pay a co-pay when their insurance requires one speaks to value in the context of the counseling relationship; either they are undervaluing you, or you are undervaluing yourself. Either way, you’re being devalued.

ANYWAY. The ACA Ethical Code that I’m referring to directly is A.10.c, Establishing Fees. You have to be able to legally do so if you’re going to adjust someone’s fees. If you are under an insurance contract, which is a legally binding document, you generally can’t not accept copays or deductibles.

The bigger ethical issue here, in my opinion, is the relationship. There’s a big ol’ boundary issue at play here, primarily. (“Boundary” is my third favorite fighting word.) Our clients always test how permeable our boundaries are, and it’s up to us in the power-up position (as much as I hate to admit it too, we are!) to maintain those boundaries appropriately. Moreover, you reinforce the power differential by putting yourself in the position of being the decider of whether or not a copay or deductible should be collected. (I know. You’re thinking, “What? How’d you get there?” Bear with me as I explain my point.) If you decide to waive copays, you are inadvertently saying to your client, “I am the one who determines whether or not you spend this money on this service.” In all reality, if you are getting reimbursed by insurance, the decision is actually out of your hands. (If you are a private pay clinician, that’s another determination entirely.) And! And and and! If we are private pay clinicians, we say that we want the determination of how much a client pays for services to be collaborative, but it’s not. If a client has to financially undress for you in order to get a lower rate for services, you’re not on equal footing even more than before finances overtly came into the relationship.

Surely, payment for services is a nuanced idea, whether we’re contracted with insurance companies or not. It’s a complicated issue, to be sure, and one that I’m sure will be revisited.

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