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One of the most common complaints a medical practice receives is related to service billing. Patients will often be informed at registration that there is an expected amount due at that time to be seen. Then, the patient might receive another bill from the provider once the claim for the visit has been processed indicating that the patient still owes some portion of the charges from that visit. For many, it can be not very clear why they must pay before and after an appointment. 

Below are some standard terms and definitions related to charges a patient might be required to pay for medical care. Individual insurance plans may vary, so the best advice is to contact your insurance company for full details about your plan.

Copays, coinsurance, and deductibles are all terms related to health insurance and represent different ways you share medical expenses with your insurance provider. Here’s a breakdown of each:

  1. Copay: A copayment, or copay, is a fixed amount you pay for a covered health care service at the time of receiving the service. For example, you might have a $20 copay for a doctor’s office visit or a $10 copay for a prescription medication. Copays are often standardized amounts set by your insurance plan and may vary depending on the type of service.
  2. Coinsurance: Coinsurance is a percentage of the cost of a covered health care service you must pay after meeting your deductible. For instance, if your coinsurance for a particular service is 20%, once you’ve paid your deductible, you would be responsible for paying 20% of the cost of that service. In comparison, your insurance company would cover the remaining 80%. Coinsurance is more commonly associated with high-deductible health plans and can apply to various medical services, such as hospital stays or specialist visits.
  3. Deductible: A deductible is the amount you must pay out of pocket for covered health care services before your insurance plan starts to pay. Once you’ve paid your deductible, your insurance coverage typically kicks in, and you’ll generally only need to pay coinsurance or copays for covered services. Deductibles can vary widely depending on your insurance plan, and they reset annually, meaning you’ll need to meet the deductible again at the start of each new coverage period.

In summary, copays are fixed amounts for specific services, coinsurance is a percentage of costs you pay after meeting your deductible, and the deductible is the initial amount you must pay out of pocket before your insurance coverage begins. Remember that the physician, practice, or facility must collect copays and send bills for any outstanding or due balances per their agreements with the various commercial (ex, BCBS, Aetna, Cigna) or federal (Medicare, Medicaid) insurance plans. Many will work out payment plans if you contact them. 

Understanding your insurance plan, what is covered, and what costs you might incur will prevent any surprises when you are seen. 

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