I paid my co pay, why am I getting another bill?
Many people do not understand how health insurance works. They are puzzled when the get a bill from a office visit or hospital when they thought they paid their part. Insurance claims can be complicated and many times the doctor has made an error in coding, which can make all the difference in what the insurance company pays.
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.
For example, an office visit from a coding perspective includes 5 Levels of codes. The levels reflect patient status and complexity of the office visit. These 5 codes typically are what is covered under a copay. If there is any other code, such as for lab test or x-rays, you will likely encounter other charges.
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 at the time of services you have not meet your deductible then you are responsible for the total charges until you have paid that deductible amount out of pocket for the year. If you used a in network provider or facility you will be charged a negotiated rate.
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.
One of the most confused subjects of health insurance claims is Preventative exams. Most plans cover them with limits. Usually one per year and only certain test are included. There may also be a monetary limit such as $300. If you go in for a physical, but your doctor ends up treating an illness, be sure your doctors office codes the visit as office visit instead of your annual preventative exam.