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.
So you paid your copay when you went to the doctor and now youre wandering why you are getting a bill from that visit. Well if the bill is for lab or x-rays, then that is because typically these procedures are not covered under the copay. Many people do not understand this.
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.
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.
One thing to pay close attention to is whether your insurance carrier goes by calendar year or anniversary date when computing deductible, co insurance and preventative care used. This one little detail can make a huge difference in your responsibilities.
If you have a preventative benefit it is important to understand its limits. It likely has a maximum payout and will only cover certain procedures. If you think you need a preventative exam because you have been feeling a little off, then do not schedule as a preventative exam, this code will be rejected if used twice in one year.