Health Insurance can be complicated. Many times people get confused and frustrated when they get a bill in the mail for an office visit that they paid a co pay for. Understanding how claims and payments work can be complicated. It is important to understand the concept.
When you visit the doctor you may have a copay. So if you paid your copay at the visit you should not expect to pay anymore, correct? Not always so. Some tests and procedures done in the office visit may not be covered under the copay.
It all comes down to how the visit is coded as well when your doctor send in the claim to your insurance company. An office visit can be coded at 5 different levels and this is what a copay usually covers. Any other code usually falls under the deductible portion of health insurance, which we will discuss later.
If the charge does not fall under the copay then it is likely subject to deductibles and co insurance. The amount you pay is based on negotiated rates if you have seen a in network physician and deductible and co insurance status at the time of visit.
If at the time of services you have not meet your deductible then you are responsible for the total charges until you have paid that deductible amount out of pocket for the year. If you used a in network provider or facility you will be charged a negotiated rate.
If your deductible has been meet, but you have co insurance also then you will also be expected to pay a portion of the charges. Lets say you have a 80/20 co insurance. Well then you will have to pay 20% of charges (20% of the negotiated charges if using in network provider) until your co insurance max. has been satisfied.
When discussing deductible, co insurance and annual benefits such as preventative care you need to understand whether your insurance provider uses calendar year or anniversary date. This can make a huge difference in your responsibilities.
If you have a preventative benefit it is important to understand its limits. It likely has a maximum payout and will only cover certain procedures. If you think you need a preventative exam because you have been feeling a little off, then do not schedule as a preventative exam, this code will be rejected if used twice in one year.
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