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.
Okay, so you went to the doctor paid your copay, all is good. Not always sometimes you may encounter additional charges not covered under the copay and get an additional bill. Sometimes lab tests and x-rays are not covered under the office visit.
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.
After years working in medical claims, I have had to explain countless times how co insurance works. If you have meet your deductible, your insurance then moves into the co insurance phase. Lets pretend you have a 80/20 co insurance. Then even if deductible is meet you will still be responsible for 20% of the charges 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 are only allowed 1 preventative exam a year, then you better be sure your year us up before the next exam or you will be paying for that exam out of pocket. Also make note if your preventative benefit has any limitations or maximum payout. If you are going to the doctor for what you call a check up because you have been having some sort of symptom, this is not a preventative or well visit, so make sure your doctor does not code it that way.
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