Author Topic: PLEASE HELP  (Read 2045 times)

ruthie72

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PLEASE HELP
« on: February 26, 2013, 06:42:34 AM »
I am confused. If a patient has a $20 copay and they pay the physician. Is that all they are responsible for? Can you please answer this question for in network and out of network? Thank you so much.

PMRNC

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Re: PLEASE HELP
« Reply #1 on: February 26, 2013, 07:53:45 AM »
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I am confused. If a patient has a $20 copay and they pay the physician. Is that all they are responsible for? Can you please answer this question for in network and out of network? Thank you so much.

That really can't be answered with one answer. It depends on the plan. Some plans have coinsurance and deductibles, some have copay's and deductibles, some only have copay's. It depends on the plan and then it depends on the provider's contract status as well.   The best way to know ahead of time is by verifying benefits before the patient comes in so you know exactly what's going to be out of pocket.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

ruthie72

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Re: PLEASE HELP
« Reply #2 on: February 26, 2013, 11:06:32 AM »
Scenario:

Patient has 1,500 Deductible, has not met..has a $25 copay. I bill the insurance the allowed amount is $62, doesn't the patient have to pay the copay and the $62 to the physician? My physian does not seem to understand this...now I am confused lol.

DMK

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Re: PLEASE HELP
« Reply #3 on: February 26, 2013, 12:11:14 PM »
This is pretty basic information that you especially and the doctor particularly needs to understand:

Scenario - Patient has a $1500 deductible, $25 co pay, (and just for example) 20 visits allowed per year.  And the doctor is participating with NO special contract negotiations.

The patient has to meet the deductible 1st. Deductible is reduced every time they go to ANY doctor, have labs done, or studies taken.  It includes ALL medical services.  It doesn't matter what the co-pay or co-insurance is until the deductible is met, the patient will owe the whole allowed amount (as determined by the insurance company) until the deductible is met.

Once the deductible is met, THEN the $25 co-pay per visit kicks in.  They pay $25 per visit, the insurance company will pay the rest.

If they go over the 20 visits allowed (or $ amount per year allowed, or whatever limitations there are on the insurance policy if any) then they owe the total amount of the visit again.

While a patient is meeting their deductible, it's always best to AT LEAST collect the co-pay.  You KNOW they will owe that much.  That way if they meet their deductible and don't tell you, you won't have so much to refund.  Also, if they can't pay the full amount of each visit at the time of service their bill won't be so huge.

I hope this helps.  This is pretty basic information, but really important for you and the doctor to understand if for no other reason than YOU WILL have to explain it to the patient in a way they can understand.  And I can't tell you how many people don't understand their own insurance and what all the terms mean.




PMRNC

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Re: PLEASE HELP
« Reply #4 on: February 26, 2013, 12:21:52 PM »
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Patient has 1,500 Deductible, has not met..has a $25 copay. I bill the insurance the allowed amount is $62, doesn't the patient have to pay the copay and the $62 to the physician? My physian does not seem to understand this...now I am confused lol.

Is this the same patient where the plan actually paid? If so if they paid, obviously patient deductible has been satisfied. If not the carrier takes the first $1500 of covered charges and applies it. The ONLY way to know if it's satisfied is to either ask patient to bring in an EOB that shows it's satisfied OR call the carrier. This is one of the reasons verifying benefits is essential. 

Now one more thing.. WITH Some plans they will only have a "deductible" by going OUT of network. PPO's are known for that mostly.  That could be another reason you didn't see a deductible being taken out on that claim. The deductible might only be an out of network deductible.   VERIFY Benefits.. best way to know ahead of time :)
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

ruthie72

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Re: PLEASE HELP
« Reply #5 on: February 27, 2013, 11:10:18 AM »
DMK thank you so much. That is actually how I explained it to my provider..and Linda thanks so much again..Yes I have been trying to verify as much as possible..