Understanding your Insurance Coverage
Insurance plans are unique and differ person-to-person and plan-to-plan.
The best and most efficient way to understand your insurance coverage is to contact your insurance provider via telephone or through their website. You are responsible for fully understanding your insurance coverage and benefits. Understanding your benefits is detrimental to your healthcare success.
Below is a list of commonly used insurance jargon to aid in your insurance success.
ALLOWABLE FEES and CONTRACTED RATES
An allowable fee is a flat rate charge that is determined through the medical facilities' contracted rates (what an office can charge for a specific visit) according to the insurance company.
CO-PAYMENTS
Co-payments apply anytime a patient is seen by a PROVIDER, i.e.; The Nurse Practitioner, Physician Assistant OR Doctor. It is an insurance company MANDATE that co-payments are collected at the time and/or on the day service is rendered, and cannot be “billed.” It is ILLEGAL for a physician or facility to “waive” a co-payment.
PLEASE NOTE: We cannot speak to or comment on what other physicians or facilities may do or how they choose to conduct business. However, we will ALWAYS follow the terms of our contracts with insurance companies, which includes collecting co-payments and deductibles at the time of service.
DEDUCTIBLES
This term refers to the amount that a patient would need to pay within a calendar year before insurance benefits and co-insurance apply.
OUT OF POCKET
This term refers to a set total amount of money you will pay towards after you have met your deductible.
CO-INSURANCE
Co-insurance is the percentage of the medical visit insurance will cover after the deductible has been met. It would be met by you during past medical visits.
WELLNESS VISIT
Most insurance companies cover one wellness visit per year at 100%. This means that there is no patient cost at time of service. Insurance will pick up the total amount charged. This can change depending on your insurance.
The best and most efficient way to understand your insurance coverage is to contact your insurance provider via telephone or through their website. You are responsible for fully understanding your insurance coverage and benefits. Understanding your benefits is detrimental to your healthcare success.
Below is a list of commonly used insurance jargon to aid in your insurance success.
ALLOWABLE FEES and CONTRACTED RATES
An allowable fee is a flat rate charge that is determined through the medical facilities' contracted rates (what an office can charge for a specific visit) according to the insurance company.
- Insurance has contracted rates with each medical facility. Contracted rates/allowable fees are a percentage of the cost of the service. Each contracted rate differs per facility and type of visit or exam.
CO-PAYMENTS
Co-payments apply anytime a patient is seen by a PROVIDER, i.e.; The Nurse Practitioner, Physician Assistant OR Doctor. It is an insurance company MANDATE that co-payments are collected at the time and/or on the day service is rendered, and cannot be “billed.” It is ILLEGAL for a physician or facility to “waive” a co-payment.
- Co-pays can change depending on the place you receive medical attention. For instance, your co-pay at a doctor's office can be $20.00, while an emergency room visit can be $250.00. Again, it is specific to each plan.
- Some plans do not have co-payments.
- Co-payments are not collected at time of service when going to a lab for blood draw only OR when seen by a medical assistant for injection only, such as a flu shot.
PLEASE NOTE: We cannot speak to or comment on what other physicians or facilities may do or how they choose to conduct business. However, we will ALWAYS follow the terms of our contracts with insurance companies, which includes collecting co-payments and deductibles at the time of service.
DEDUCTIBLES
This term refers to the amount that a patient would need to pay within a calendar year before insurance benefits and co-insurance apply.
- Unmet deductibles are subject to allowable fees and will be collected on the date of service at the appointment.
- They are specific to each plan and type of insurance.
OUT OF POCKET
This term refers to a set total amount of money you will pay towards after you have met your deductible.
- If you meet your deductible and out of pocket, then coinsurance is 100% coverage.
- Depending on your unique plan, there could be an out of pocket max per calendar year. This date could start at the beginning of coverage date or be a lifetime amount.
CO-INSURANCE
Co-insurance is the percentage of the medical visit insurance will cover after the deductible has been met. It would be met by you during past medical visits.
- Applicable co-insurance (usually a percentage of the total visit charge) is also collected on the date of service, unless a secondary insurance covers the balance.
WELLNESS VISIT
Most insurance companies cover one wellness visit per year at 100%. This means that there is no patient cost at time of service. Insurance will pick up the total amount charged. This can change depending on your insurance.
- These visits are routine physicals.