How much will I owe?

“How much will this cost me?”

This is an understandably popular question among my patients. The answer is: it depends on your insurance, and upon your plan. Health insurance has become very complicated in the last several years.

As you probably know (or may not know), insurance works like this:

  1. You visit the health provider.
  2. Provider submits bill to insurance.
  3. Insurance reviews the claim, and, if they agree to pay it, states how much they will pay. This is called the “allowed amount”.  The insurer sets this amount.  I do not.  I do not have any say in how much this amount is. It can vary wildly between insurers and even between plans. However, some insurers have an online tool that will let the doctor or patient estimate how much a visit or service will cost ahead of time.
  4. The insurer sends you and the provider an “estimate of benefits” showing whether or not they agreed to pay, and how much. If the insurer is paying anything, they will send the provider a check. If they are not paying anything, they will tell the provider why and how much they would have paid if they were going to pay. (This is like the “how much wood could a woodchuck chuck…”… how much would an insurer pay if it could pay?)

So, you may owe any combination of the following:

  1. Copay – this is a set amount such as $10 or $30, that you pay for each visit of a certain type.
  2. Co-insurance – this is a percentage of the allowed amount. It may be 10%, 20% or higher.
  3. Deductible: this is the amount of money that you have to pay on medical bills before the insurance  starts paying. Amounts can vary from semi-reasonable ($300) to enormous ($6000).  You probably have a deductible for “in-network” services and “out of network” services. The out of network deductible is far higher.

The amount that you will actually end up paying depends upon how much you owe in co-pay, and how much you have left in deductible, and in how much is “allowed” for the service.  Also it depends on if  a provider is in or out of network for an insurer. If a provider is out of network” then they can usually ask you to pay the full amount they billed the insurance. A provider who is in-network has agreed to only bill you for up to the amount that the insurer “allows” for that service.

So, let’s take some examples. (These are all made up figures.) Let’s say that you go to Dr. Y, who is a well-known specialist, and have an office visit.  He is in network with your insurance. You have a co-pay of $35 for specialists. Dr. Y bills your insurance $300. Your insurance decides that it will cover the visit, and that the total allowable amount it will pay for this visit is $130.

  • If your deductible is met, then all you owe is $35. The insurance pays the doctor $95. ($130 – $35 = $95).
  • If your deductible is not met, then you will owe both the $35 (for the copay) and the remainder of the visit not covered by the deductible, or up to $95.

What if Dr. Y isn’t in network? Then, in most cases, Dr. Y can “balance bill” you, and ask you to pay any of the full $300 not covered by the insurance company. This is unless Dr. Y graciously states that “they accept the allowable”. (This may  differ for Medicare and Medicaid patients.)

Balance billing is a hot topic right now, with states and the US  government considering acting to limit balance billing for emergency out of network services.

So what do you need to know for your visit with me?

  • sometimes I am able to determine ahead of time about how much  a visit will cost you. However, in general visit costs with me are lower than with many other providers.
  • In general, we can usually find out if I am in network with your insurance or not before you come in.
  • If the visit ends up costing you more than you anticipated, then we can work out a payment plan.
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