Copays, Deductibles, And The Explanation Of Benefits For Health Insurance
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Copays, Deductibles, And The Explanation Of Benefits For Health Insurance

Since the implementation of the Affordable Health Care Act, more people in this country have health insurance. Some people have health insurance for the first time in their lives. Even those who have had health insurance for many years often do not understand the terms of their health insurance and what it will or won’t pay until they need to receive health care. With more people struggling to understand the terms of health insurance, a medical billing service makes even more sense for busy doctor’s offices.

Following are some of the terms that patients need to understand about their health insurance and that the medical billing service will consider when taking care of your billing needs:

• Co-Pay – This is the amount you will pay out-of-pocket whenever you receive medical care and, depending on your coverage, when you have prescriptions filled. Often, the amount of the copay is different for specialists or emergency room visits than for visits to your primary care physician. It may also be different for some types of tests or for lab work. Some insurance coverage does not have copay but these are usually more expensive insurance plans. Physician’s offices vary between collecting the copay when you see the physician or having the medical billing service bill you after your claim has been submitted and processed.

• Deductible – The deductible refers to the amount you will need to pay upfront. Once paid, your insurance company will pay any allowable amount. The higher the deductible, the lower the premiums will usually be. However, a deductible that is too high could result in significant health care bills if you have a serious condition or accident that requires hospitalization or some types of treatments. Some people will increase their deductible in order to make their monthly premiums more affordable.

• Out of Pocket Maximum – This is the most you will have to pay out of pocket during a year. Keep in mind that for family health plans, the maximum amount is usually per person.

• Explanation of Benefits (EOB) – Once the medical billing service has sent your claim in and the insurance company has processed it, you will receive an EOB form. This is not a bill, but an explanation of what amounts you have been charged for services, the portion that the insurance company is going to pay, and the amount of the difference between the two. Sometimes the physician’s office will give discounts on services that are above the maximum that the insurance will pay (the allowable charge). This will usually be reflected on the EOB. You will usually receive a bill for the amount you owe after receiving the EOB.

• Network Provider – Some insurance companies require you to go to a physician who is listed in their network before they pay for your medical care. Others may pay a portion of coverage for non-network providers.

Health insurance is a complex system that differs from one provider to the next. A medical billing service can not only prevent you from using your valuable time to take care of your billing needs, but they can also help patients understand their insurance options and their financial obligations for medical care.


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