By Trish Pearson
Insure Your Future
Trish Pearson
When a person sees a physician or other provider, there is generally a copay involved. When a patient visits a provider, they may receive multiple services during the same visit. Often services like blood tests, x-rays and MRIs have a copay when they are separate visits. However, if the additional services are part of the office visit, some providers accumulate the charges separately so that the copays “stack up.”
This can become expensive. Do not assume that the amount due is correct until after the insurance company has processed the claim.
Here is what to look for: Does the statement from the doctor reflect the amount that was covered by insurance? The insurance amount should be close to what is reflected on the explanation of benefit from the insurance carrier. If not, it could mean that the insurance benefit has not been deducted from the charge, or that the provider is billing for the full amount instead of billing based on the amount the plan approved.
The patient is only responsible for paying the difference between the approved amount less the amount the insurance company paid. In general, services provided during an office visit are covered and the patient is responsible for one copay. Always request an explanation from the provider as well as the insurance company to make sure everyone is “on the same page” regarding the charges.
Copay stacking will often occur because of an emergency room visit. The emergency room copay should cover whatever services are provided. For example, if the copay is $125 it will include any blood work, lab costs or MRIs. For people on high deductible plans, it is especially important to make sure services are not charged separately, as the patient is responsible for all costs until the deductible is met.
A second example is if the copay for a specialist is $60 it should include the cost of blood work or an x-ray if done in the office. Some insurers will only bill for the highest level of services provided during the visit. This is why it is important to wait for the EOB to come before paying any bills.
The best way to see an EOB quickly is through an online account with the insurance carrier. An online account with the insurance carrier is a valuable tool and provides information much more quickly than waiting for the mail to arrive. Need help setting up an account? Contact member services on the back of the ID card and they will explain each step.
Another gray area in the medical cost arena are facility fees. Generally, a facility fee may be charged if the provider performs a procedure during an office visit or as part of one-day surgery. The facility fee can vary depending on the medical facility and the type of service.
Again, the patient should question the provider if he or she is charged a separate facility fee as well as the insurance carrier. The consumer should take the position that the outline of benefits states that the copay for a visit or service is a certain price and question the validity of the facility charge. It requires some phone calls and perhaps time on hold, but it could very well be time well spent.
Trish Pearson is a licensed independent insurance agent and certified long term care specialist. Contact her at 203-640-5969 or trishpearson281@gmail.com.