Most health insurance plans require co-payments, have deductibles, and/or have co-insurance percentages. These are amounts owed by the policy holder or patient and can vary from one insurance plan to another. The co-payment amount, deductible amount, and co-insurance percentages are usually listed on your insurance card and more details about your insurance plan can be found in your policy handbook.
Co-payment:
A cost-sharing arrangement between the policy holder and their insurance plan in which you pay a specified amount for a specified service within a participating network, such as $15 for an office visit. You usually make your co-payment at the time the service is rendered. Co-payments may be in addition to certain co-insurance and deductible payments. Many insurance plans have higher co-payments for specialist visits and emergency room services.
Deductible:
A dollar amount you must pay out-of-pocket before the insurance company begins to pay at the co-insurance level. For example, if you have an individual deductible of $200, you must pay $200 of your health care costs before your insurance company pays any percentage. A family deductible defines how much your family must pay out-of-pocket before insurance pays any percentage. The deductible calendar year may vary. Please refer to your insurance plan manual for specifics regarding your plan.
Co-Insurance:
Cost sharing between you and the insurance company, defined as a percentage. For example, suppose a policy offers 80/20 co-insurance on the first $5,000 of medical claims. The insurance company would pay 80% or $4,000 of the first $5,000 of medical claims and you would pay 20% or $1,000, after which the insurance company will pay the remainder as defined in the policy. Coinsurance often applies after you meet your deductible.
You may have received an Explanation of Benefits (EOB) from your insurance company. An EOB is not a bill! It is for your information only. The EOB will show how your insurance company processed the charges that were submitted to them by the provider. An EOB will show how charges were paid, tell you why charges were denied, or indicate what additional information, if any, is needed and who needs to submit the additional information for processing of the claim. If the EOB shows an amount due, a bill will be sent to you for services rendered by the provider.
Your health insurance coverage is defined in a contract between the insurance company and you. While our staff can help you to understand your charges, you need to call your insurance company with questions regarding unpaid charges.
The amount you are billed for is based on what your insurance communicates to us on an explanation of benefits (EOB). The EOB details how your insurance processed our bill and calculated your responsibility based on your individual insurance plan. If you believe your responsibility is not correct, please contact your insurer directly.
We will process and send a bill to a patient after payment is received from the insurance carrier and it is confirmed that the balance is owed by the patient. The length of this process depends on how long it takes to receive a response from your insurance carrier, and whether there is secondary insurance.
Medicare coverage has two parts. Part A primarily provides hospital insurance, but also includes limited skilled nursing home care, hospice care, and some home health care services. Medicare Part B primarily provides medical insurance and includes doctors’ services, outpatient hospital care, and other medical services that are not covered by Part A. If you only have Part A coverage, you will be billed for provider services and other uncovered expenses. Medicare also has an annual deductible and co-insurance, and does not pay for non-covered services nor elective procedures.
Please go through your statement carefully. Under the column “Date insurance billed,” you will see the date that we billed your insurance. If you are still uncertain, you can either contact your insurance company directly or contact the Patient Services department at the number mentioned on your statement for further assistance.
The insurance company has the most accurate and up-to-date information about the policy and claim. Insurance agents can tell you if the procedure or service received is covered by the policy. The insurance company can also verify that it received and processed the claim.
“Adjustment” refers to the portion of your bill that your hospital or doctor has agreed not to charge you.
Medical claims must be billed by a practicing doctor. If you saw a nurse practitioner or physician assistant, that person’s supervisor (a practicing doctor) would have billed the charges.
Your doctor also may have ordered tests that need review or interpretation by a specialist. (For example, if you had an MRI, your doctor may have had a radiologist review the results.) So while you may not have seen the doctor who reviewed your test results, you are still billed for his or her services.
Please have your statement and insurance card available and contact the Patient Services department at the number mentioned on your statement. A Patient Representative will ask for information from your insurance card, make the necessary corrections in our billing system and have the claims reprocessed for you.
We offer payment options if special circumstances prevent the patient from making a full payment, including monthly payment installments. Don’t ignore the bill or send in less than the full payment without contacting us. Making less than a full payment without making prior arrangements with Patient Services can cause your bill to progress through our collections process. This may include transferring your account to a collection agency which can show up on your credit report. To discuss your bill and payment options, please call Patient Services at the number mentioned on your statement.
Coinsurance
Your share of the costs of a covered health care service — usually a percentage of an eligible expense. For example, you may pay 20% of an allowed service while your health insurance plan pays 80%. Generally, your coinsurance applies after you meet your deductible.
Co-payment
A fixed dollar amount you are required to pay for a covered service at the time you receive care.
Deductible
A fixed amount of expenses you are required to pay before you are reimbursed for a covered service. For example, if your deductible is $1,000, your plan won’t pay anything for some services until you’ve met your $1,000 deductible.
Dependent
A person (generally a spouse or child), other than the member who receives health care coverage under the member’s policy.
Explanation of Benefits (EOB)
The form sent to you after a claim has been processed by your health care provider. The EOB explains the actions taken on the claim, including the amount paid, the benefit available and the amount you may owe the provider, and other information, such as how to appeal a claim decision.
Out-of-Network
Services provided by health care professionals or at facilities that are not in the network of contracted providers and facilities in your health plan.
Pre-Existing Condition
A condition, disability or illness that you have been treated for before applying for new health coverage.
Preauthorization
The process by which members or their primary care physicians (PCP) notify the health plan, in advance, of plans for treatment such as a hospital admission or a complex diagnostic test.
