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.
How the insurance company pays a claim is by the codes that the doctor posts to the visit that he submits. An office visit usually constitutes one out of 5 codes used for an office visit. The Level 1-5 depends on patient status and complexity of visit. Any other codes submitted in this visit would be additional or above and beyond the office visit.
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.
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 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.
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.
How the insurance company pays a claim is by the codes that the doctor posts to the visit that he submits. An office visit usually constitutes one out of 5 codes used for an office visit. The Level 1-5 depends on patient status and complexity of visit. Any other codes submitted in this visit would be additional or above and beyond the office visit.
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.
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 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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