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UNDERSTANDING MY BILL
PrimaryMD staff recognize that insurance is confusing and can lend to much stress for patients. PrimaryMD staff are always available to assist in explaining a bill. We believe in transparency of costs and whenever possible we provide upfront pricing and estimates. Read on to learn more about the billing cycle.
A co-pay is the fixed amount of money due fro patients at the time of service. Co-pays vary from insurance company to insurance company. They can also vary in amount from specialist to primary care physician and urgent care. The amount of a patients copay is fixed by the insurance company and is typically found on the back of the insurance card. At PrimaryMD our insurance eligibility software will tell you the amount due at the time of visit. Some insurance companies apply the copay amount towards the deductible while others do not.
A deductible is the amount of money a patient must pay out of pocket prior to the insurance company paying any expenses. Deductibles can vary in amounts and the limits are set by the government. In 2016 the max out of pocket high deductible for families was $13,100.00 and $6,550.00 for individuals. This means patients will be responsible for paying for most services up to these amounts for the year. This is a very confusing aspect of shopping for insurance. Remember that higher deductible plans offer lower monthly premiums but cost the patient much more out of pocket. If you are an individual with frequent medical needs these plans may cost more in the long run.
Many health plans require patients to pay a coinsurance, or percentage sharing of the cost. This means that you’ll essentially be splitting the cost of your healthcare with your insurance carrier.
For instance, if your health plan has an 80/20 co-insurance rate, (coinsurance rates of 70/30 90/10, and flat rates of $5.00 to $20.00 per doctor’s office visit are also common) your insurance plan pays for 80% of your eligible medical expenses and you’re responsible for the remaining 20%.
This coinsurance usually ends when the max out of pocket is met.
Explanation of Benefits (EOB’s)
An explanation of benefits (commonly referred to as an EOB) is a form that insurance companies send to patients to help them understand what payments were made on their behalf. An EOB typically contains: Patient Demographic information, Services Performed, Date of the service, Description and code for the service, The provider demographicsDoctor’s fee, and what the insurer allows and the amount initially claimed by the doctor or hospital less any reductions applied by the insurer the amount the patient is responsible for adjustment reasons, adjustment codes