Health insurance can be very confusing, and navigating health care expenses can be intimidating. Often we have patients who are confused about their bills, or wonder why they didn’t have a balance for the first few months, then it came on at once. Below is a link to the AMA’s Insurance 101 handout which can be helpful in understanding much of this, and here is a brief explanation of some commonly asked questions.
When a patient comes to an outpatient medical clinic, the service provided is billed to their insurance as a code, for payment. Regardless of what we charge as our set price, the insurance company will have an “allowable fee” that they pay, if you are contracted with them. KMHM is contracted with most major insurances so the “allowable fee” is what becomes the relevant amount to be paid, in most cases. The difference gets taken away. The amount left is then divided into the insurance responsibility and patient responsibility. Depending upon the insurance plan chosen by the patient, these amounts and how things are covered can vary tremendously. A lot of insurances require patients to make a “co-pay” which is a pre-determined amount the patient must make at the time of the appointment, and it may vary depending upon what type of provider they are seeing.
Additionally, most insurance plans have a “deductible” which is a specified annual amount that the patient must pay for their health care, before their health insurance kicks in. We continue to see higher and higher deductibles on the insurance plans patients are choosing. This means that patients are having to pay more out-of-pocket before they get relief from the insurance. This particularly applies to the beginning of their insurance cycle when their deductible hasn’t been “met” yet. In addition to deductibles, many plans now have what is called “co-insurance.” Co-insurance typically refers to an in between range where the deductible has been met, but the plan specifies that the patient is still responsible for a certain percentage of their health care up until the “out of pocket max” has been met. “Out of pocket max” is the amount that once it has been reached, insurance should begin covering at 100%. These things all typically reset on an annual basis.
Delays:
We are often asked why it seems to take so long for balances to post to a patients account and then can accrue all at once. The cycle of providing service to a patient, documenting the medical record, coding it for billing, submitting it to an insurance company, getting reimbursed which typically goes through a “clearing house” can no doubt be a slow process sometimes. Often our billing specialists don’t know how much will be the patient’s responsibility until insurance has paid their part. We often have patients who are doing multiple treatments per week, and this can add up over the course of this delay. We would recommend making payments at the time of your service to mitigate some of this potential for a big balance to add up. The difficulty is knowing how much to pay, which depends on your insurance plan and where you stand within those plan specifications. We often don’t know that info either. In the case that someone would over-pay, we will simply issue reimbursement checks.
Please visit the AMA link below for more detailed description of all of this: