Insurance and Billing Questions

Understanding Your Health Care Coverage

Health insurance can be very confusing.  Often times, it is provided by your employer, and explained briefly in a benefits meeting.  For many people, they don’t learn about their insurance until after they have begun to use it, and are often surprised at the costs.

Our best recommendation is to understand your insurance before you need it.  If you have the opportunity to choose between multiple plans or carriers, it is important to understand your needs before making your selection.  The lowest cost premium may not save you money over a given year, and likewise, the highest cost plan may not provide the benefits that you need the most.  Feel free to ask for assistance from the staff of Desert Ridge Family Physicians.

Below is a brief primer of important terms relating to insurance:

Co-pay

Your co-pay is the fixed amount you pay for visiting your primary care physician (PCP). In most cases, the payment is the same regardless of the extent of the visit. For example, a plan may require a co-pay of $20 for office visits with your PCP. Some services, such as routine physicals may not require a co-payment. It is up to you to know what your specific policy co-pay requirements are.  It is required that you pay your co-pay every time you have an office visit with your doctor.

Deductible

Your health insurance deductible is the amount that you will have to pay for a claim before the health insurance pays anything.  In order for you to meet your deductible, claims must be submitted and processed by your insurance carrier. When the claims are processed, the amount that is applied to the deductible is the allowed amount for the services being billed. For example, if the claim is for an office visit charge of $94, and the insurance allows $60, then $60 will be applied to your deductible, not $94.

Co-insurance

Typically, once the deductible is met, the insurance company will pay a portion of the allowed amount, and the remaining portion is paid by the patient in the form of co-insurance.  Co-insurance is similar to a co-pay, although co-insurance generally applies to less routine expenses, and is expressed as a percentage rather than a fixed dollar amount. So if your plan has a $100 deductible and 20% co-insurance and you use $1,000 of your insurance allowable services, you’ll pay the $100 plus 20% of the remaining $900 ($180) for a total patient responsibility of $280, up to your out-of-pocket maximum. You may find plans with no co-insurance requirements, some with 90/10, 80/20, 70/30 or 50/50 coinsurance, or other combinations.

Out-of-pocket maximum

Your out-of-pocket maximum is an important feature of your health plan because it limits the total amount you pay each calendar year for healthcare including co-pays, deductibles, and co-insurance. If your policy carries a $2,500 out-of-pocket maximum and you get sick and require a lot of healthcare services, the most you will pay in a year is $2,500. After that, insurance picks up the rest of the tab. The out-of-pocket maximum helps protect you from very high additional costs. In most cases, once you reach your health plan’s out-of-pocket maximum, your insurance company will cover 100% of the costs they consider to be medically necessary. Some health plans do not count all of your out-of-pocket expenses when determining the OOP maximum. For example, your plan may not include your annual deductible and some plans may not include the co-pays associated with outpatient procedures.  You should get a document called an explanation of benefits (EOB) that shows your out-of-pocket expenses as the year goes on.

Questions About Your Bill

If you have questions about your bill, please call us at (480) 607-0060.  Your insurance company may also be able to assist you with any questions, and may also be a valuable resource.  Generally, your insurance company will have their phone number for member services on your insurance card.

Verification of Benefits and Eligibility

Desert Ridge Family Physicians will make every effort to verify your insurance coverage prior to your appointment.  Unfortunately, the information that we receive is very limited, and we are not able to guarantee coverage of services by your insurance company. While we will assist you to make sure that you have met the requirements for payment by your insurance you are ultimately responsible for payment of all services that are not covered by your insurance plan.