Insurance

Understanding Your Medical Bills: Copays, Deductibles, and Co-insurance

Navigating the world of medical insurance can feel like learning a second language. When you visit our office, you may be asked for a payment at the front desk or receive a bill later. We understand that medical costs can be a source of stress, so we want to provide clarity on how these fees are determined and why we are required to collect them.

The most important thing to know is that these fees are not set by our office. Instead, they are determined solely by the insurance plan you have chosen.

Breaking Down the Basics

When you sign up for a health insurance plan, you enter into a contract with that provider. That contract defines three main types of “cost-sharing” that you are responsible for:

• Copayment (Copay): A fixed amount (e.g., $25) you pay for a specific service, usually due at the time of your visit.

   

• Deductible: The amount you must pay out-of-pocket for healthcare services before your insurance begins to pay.

   

• Co-insurance: Your share of the costs of a healthcare service, calculated as a percentage (e.g., 20%) of the allowed amount for the service.

   

Why We Must Collect These Fees

You might wonder why we are so diligent about collecting these payments. It isn’t a policy we created; rather, it is a contractual obligation between our practice and your insurance company.

1. It’s Part of Our Contract

When our clinic joins an insurance network, we sign a legal agreement. This contract requires us to collect the exact copay, deductible, or co-insurance amounts specified by your plan. If we routinely waive these fees, we may be considered in breach of contract with the insurance provider, which can jeopardize our ability to see patients under that plan.

2. The Insurance Company Withholds These Amounts

A common misconception is that the insurance company pays the doctor in full and the patient’s payment is an “extra” fee. In reality, when your insurance processes a claim, they automatically subtract your portion (the copay or deductible) from the payment they send to the physician.

Example: If a service costs $100 and your plan has a $20 copay, the insurance company will only send the doctor $80. If we do not collect the $20 from you, the physician simply does not get paid for that portion of your care.

Our Goal is Your Health

Our primary focus is providing you with the best possible medical care. We share this information not to focus on finances, but to ensure our partnership remains transparent and compliant with the many regulations governing healthcare today.

We encourage you to review your “Summary of Benefits” from your insurance provider so you know exactly what to expect at your next visit. If you have questions about your specific coverage, your insurance member services department is the best resource for detailed answers.

We do our best to determine what your individual plan asks you to pay, but even with our AI assisted software and highly trained and experienced staff, the policy specifics that  are as shown to us by the Health Plans are often complex and lengthy and sometimes very difficult to decipher. After the billing cycle is completed and the Insurance company sends us theit EOB statement, if you have been asked to overpay, rest assured we will place the credit on your account or refund your overpayment as soon as we see it is due.

We thank you for your understanding and for trusting us with your care.