New York State Seal
STATE OF NEW YORK
INSURANCE DEPARTMENT
25 BEAVER STREET
NEW YORK, NEW YORK 10004

The Office of General Counsel has issued the following informal opinion on March 30, 2001, representing the position of the New York State Insurance Department.

RE.: Charging of Administrative Fee to Patients for Collection of Co-Payment

Question Presented:

May a physician group charge an administrative fee to a patient for the collection of the patient’s co-payment fee that was charged at the time of delivery of service which was not paid?

Conclusion:

It depends upon whether or not the charging of an administrative fee is stated in the "certificate of coverage" which is approved by this Department. If the certificate of coverage does not state that an administrative fee can be charged in the event that a patient neglects to pay the co-payment at the time of service, then it may not be charged to the patient.

Facts:

No specific facts relating to this inquiry were given.

Analysis:

The New York Insurance Law and regulations promulgated thereunder, do not discuss the issue as stated herein. However, since it is the Department’s job to approve the insurer’s certificate of coverage, restrictions exist as to what a participating provider may or may not do. The certificate of coverage is a contract between the insurer and the insured, and therefore the participating provider cannot usurp this agreement by charging a fee that is not clearly stated in the certificate of coverage.

However, if the certificate of coverage permits this administrative fee, then it is permissible.

For further information regarding this opinion, you may contact its author, Senior Attorney Meredith S. Kaufer, at the New York City Office.