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.
Part of this understanding comes from understanding how deductibles and co-insurance works. If you incur charges not covered under a copay, that charge is subject to deductibles and co-insurance. The amount you are responsible for depends on your plan.
If you have a deductible to meet you are expected to pay 100% of charges until you have paid that deductible amount out of your pocket. Of course these charges are based on a negotiated rate if you are using an in network physician or facility.
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.
You need to know if your insurance company goes by calendar year or anniversary date. This makes a huge difference and is reason for much confusion for many. If they go by calendar year then no matter your time of policy purchase everything (deductible and co insurance ) will start over on January 1st.
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.
If you would like to make a comment, please fill out the form below.
