What is a Copay?

Continuing the round of "definitional" posts to get this blog started ... it's time to talk copays.

Copays are fees that you are required to pay each time you have a particular service under your health insurance. These fees take the form of a flat dollar amount that you pay each time you have a particular service - for example, $15 per office visit or $50 per emergency room visit.

What is a Deductible?

So, the first round of posts at this place will be a few definitions of common insurance and medical billing terms that are helpful for people to understand when trying to decipher mounds of insurance paperwork. Once we've established the key terms that you might hear while you're trying to navigate your medical billing and insurance issues, we can start talking about what you should do if you encounter a range of common problems.

Okay, so first off: What is a Deductible?

The term "deductible" refers to the amount of money that a patient (or family) is required to pay toward their medical expenses before their insurance company will begin making payments on claims filed on their behalf.

In other words, once you begin coverage with an insurance policy, they will immediately process all claims sent to them on your behalf. However, they will not make payment on any of your claims until they have received $1000 (or however much your deductible is) in charges from various doctors. So your doctor's office will send the claims to your insurance like normal, but you will ultimately be billed by your doctor for the full amount of the bill* and you will be fully responsible for payment. Once you have been billed for the first $1000 (or whatever your deductible is) of treatment, your insurance will begin to actually make payments on your behalf to your doctors' office.

Deductibles reset every policy year (so you should make careful note of the start date of your policy), so that you will have to pay the first portion of your medical charges out of pocket every single year you are on the policy.

Deductibles also apply to patients, not to a specific doctor. So you will not have to pay a separate deductible to each doctor's office - just one per patient per policy year.

You will probably have two separate deductibles listed on your policy - one for in-network doctors, and a higher one for out-of-network doctors. We'll talk more about the distinction between them in the future. For the time being, though, try to see only in-network doctors whenever possible.

It's worth noting that some policies will have exceptions to the deductible listed in the contract - they will agree to pay for two office visits before the deductible kicks in, for example ... or not apply the deductible to preventative care services or prescriptions or something similar. If you have a policy like that, make sure that you pay careful attention to what services are exempt from the deductible, and make sure your insurance company processes those bills correctly.

Obligatory Introductory Post

Hello, and welcome!

I'll keep this short, since let's face it ... you're not here to listen to me talk about myself and share witty anecdotes. You're here because you would like to know more about your health insurance coverage or about the confusing statement you've just gotten from your doctor's office after some treatment that you had.

If you're like most people, your insurance paperwork and medical bills probably resemble gibberish written in a foreign language. Columns of numbers and unfamiliar words and "explanations" that are written in jargony language that you don't understand. Maybe this makes you feel stupid or uninformed. You're an intelligent person, right? After all, you knew enough to get yourself a job with health benefits, or to shop around and buy an individual health plan. Why can't you figure out this insurance gibberish???

Here's the dirty secret: you can't figure it out because it works in your health insurance company's (and often your doctor's) best interest to make your bills and statements as unclear as possible. Simply put? They're hoping that you'll give up trying to understand what's happening and just pay what they tell you to pay. Remember - every bill you pay is a bill that the insurance company doesn't have to pay. And if the insurance company doesn't pay, they benefit financially. So it's not in their best interest to make sure you understand your benefits and bills.

As for the doctors' office? They just want to get payment from somewhere. In many cases, the doctor's billing office will help you appeal to your insurance company if there is a problem. And if they're a good billing office, they should take the lead in appealing problems when they arise. 

But ultimately, the doctor's office just wants to get paid from somewhere so that they can close your file. If you pay a bill your insurance should have paid? It's all the same to them.

So sadly, the onus is on you - the patient - to understand your benefits and to monitor your bills and deal with any problems that arise. It's not easy, but it's necessary.

And I'm here to help. After all of these years working in the industry and only being able to help patients who come into the offices of the few doctors I work for, I wanted to create a website where people in general can get the help and answers that they need for questions about health insurance and medical billing.

While I am unable to provide help or assistance regarding particular health insurance or billing problems that you, individually, are having, I welcome any comments or suggestions for general topics I should cover in future posts. I can be reached at medbillhelp (at) gmail [dot] com.

Thanks for reading!