Insurance Overview
Will this be covered by insurance?
This is a question we encounter often, and it’s not always an easy one to answer. We can usually tell you if a visit or procedure is “covered” by insurance, but that doesn’t necessarily mean you won’t have to pay anything out of pocket.
Here is a brief summary:
- Patients have contracts with insurance companies that determine how much they pay.
- Doctors have contracts with insurance companies that determine how much they get paid.
- Both of these contracts are binding and non-negotiable.
- We do our best to control costs by avoiding unnecessary procedures.
Your health insurance policy is a contract between you and the insurer that defines which health care services are covered and how much you are responsible to pay for the services you receive. Plans often differ significantly from patient to patient. Even where you stand within your own plan is constantly changing based on how much you have paid for your health care up to that point. We’ll try to explain below:
First, let’s look at a few terms you have likely heard before.
Copay.
This is the set amount you pay at each visit and it is usually collected at the time of your visit, either at check in or check out. The amount may be different for visits with your primary doctor than with a specialist. (For example, you may pay $20 to see your primary doctor and $40 when you see your dermatologist.) This may not cover the cost of your entire visit, so you might still receive a bill in the mail depending on how much of the visit insurance covered.
Deductible.
This is the amount you have to pay out of pocket before your insurance “kicks in.” So, if you have a $1000 deductible, you may be responsible for all of your medical bills until you have paid that amount.
Coinsurance.
Even once you’ve met your deductible you will still be responsible for a portion of your medical bills. It’s pretty common for insurance to start paying 80% of the bill after you have met your deductible, leaving you responsible for the remaining 20%. Again, your plan may have different numbers.
Out of pocket maximum.
Your plan also specifies an amount that, once reached, the insurance company cuts you a break and starts paying 100% of your medical bills. We’ll use $3000 as an example.
So, let’s suppose you haven’t met your deductible. You show up for your visit and pay your copay of $20 or $40 or whatever yours may be. The visit ends up costing $200. We send the bill to your insurance. Your insurance looks at the bill, sees that you have not yet met your deductible, so you get a bill for the remaining balance.
Suppose you have met your deductible, but not your out of pocket maximum. (You have spent more than $1000 out of your own pocket, but less than $3000). You will still pay your copay at the time of your visit and you may be responsible for 20% of the cost of the visit, with insurance covering the other 80%. Again, the bill goes to insurance first.
Now let’s suppose you’ve met your out of pocket maximum. Everything should be covered.
It is important for you to understand that all of this is predetermined. These payment arrangements have already been made and cannot be changed.
Doctors have contracts with insurers, too. Our contracts dictate how much we charge and how much we are to be paid for our services. We cannot charge you any more or any less than what we have contracted with your insurer. Our contracts with insurance companies are binding, non-negotiable, and highly regulated by the government, insurance commissions, and medical boards. Doctors may be audited to ensure they are in compliance with these laws and regulations.
At our clinic, billing is integrated into the electronic medical record system. This allows for efficient, highly accurate, transparent and fair billing practices. Here’s how it works.
During your visit, the medical assistant creates a note in the electronic medical record detailing the exam and procedures performed by the doctor. The system then automatically generates billing codes based on what is documented in the medical record. Once the doctor reviews and finalizes the visit note, the billing codes are electronically sent out to the automated billing service, which sends the bill to your insurance company.
If you believe you were billed for services that WERE NOT performed, please contact our clinic manager.
If you feel that you were charged too much for services that WERE performed, please contact your insurance company.
Cosmetic visits and procedures deemed cosmetic that are performed during the course of medical visit are not covered by insurance. The costs of these visits and procedures are the responsibility of the patient and must be paid prior to services rendered.