Who gets to 'Keep the Deductible and Copays' --- Doctors or Ins. Co. ???

[Mike Siegal]

I'm trying to figure out how the 'payment for services' works when a Covered Med Patient has to pay a deductible, and copay before full coverage begins,...

'Who gets that money?'

EX.
Lets say Betty has been diagnosed with Cancer and has to see an Oncologist. Her out of pocket deductible is $5000 and her MOOP is $7500. --- Before the insurance pays 100% of her Dr. Visits and/or Treatments, she pays the copay and deductible.

• Does she pay it per Dr. Visit --- and this is applied towards her insurance deductible?
• Are all copays collected by the Dr. or -- do patients get billed by Ins. Co. ?

Thoughts /comments?

Thanks for your input!

 

[LostDollar]

Caveat, not an agent.

My experience as a patient, EGH plans and Medicare Part B.

Patient's first claim of year. Patient has a deductible to meet.

Provider files a claim for services with the insurance company.

The insurance company prepares an eob saying the patient owes the money because they have not met their deductible.

The insurance company sends a copy of the EOB to the provider and the patient.

The provider sends the patient a bill.

The patient compares the provider bill to the insurance company EOB and pays the provider.

Insurance company is just a scorekeeper using claims data from providers and terms of the patient's health plan. Insurance company bills are for plan premiums.

Co-pays are just a portion of the provider charge not reimbursed by insurance according to plan terms and are collected by the provider (often immediately after the service is provided) as a partial settlement of the patient's bill.

 

[Yagents]

I don't understand the question. But copays if available reduce the out of pocket max and don't go towards the deductible. Expenses subj to deductible go towards ded and OOP is reduced

 

[rousemark]

The money for go pays are paid to the Dr. They are the part of the zdr bill not paid by insurance.

 

[Mike Siegal]

I don't understand the question. But copays if available reduce the out of pocket max and don't go towards the deductible. Expenses subj to deductible go towards ded and OOP is reduced

The question is 'Does the doctor accept the deductible dollars from the patient' or 'does the patient send any 'Deductible money due' directly to the insurance company?

Like I mentioned above, if the deductible is 5k, does the patient make the deductible payment while at the Doctors office at her next visit (or does she give it to the insurance company) ?

LETS SAY the patient has 10 appointments scheduled with the Oncologist --- does she make 10 $500 payments to the doctor...or does she send that money to the insurance company?

NEXT; is this money credited towards Doctors Visit Charge ??? ---- (at this point the doctor wouldn't be reimbursed by insurance company UNTIL the entire deductible is met).

The money for go pays are paid to the Dr. They are the part of the zdr bill not paid by insurance.

 

[LeeV]

To begin with, there can be a variety of scenarios because of how the providers may or may not act with respect to their billing procedures and the payments due. A few things first, to answer your questions.

No, the patient does not make the deductible payment while at the doctor’s office. The patient will pay according to the plan of benefits. If there is a $50 copay, they will pay that. If the office visit benefit is something along the lines of “Deductible+Coinsurance”, they will pay the full amount of the physician office visit, such as $500 if that is the cost.

No, the patient does not send any money to the insurance company in your question above.

The most common scenario is when a provider confirms eligibility and benefits with the plan. If the first provider is a physician’s office and the plan has a copay, such as $25, they will charge the patient $25. That $25 goes against the MOOP. Let’s assume a visit to an imaging center, where the cost is $1,000, again that office will verify eligibility and benefits. If the insured has not satisfied the deductible the imaging center will be told that. Based on your schedule of benefits and the earlier $25 copay, the insured will be responsible for the $1,000 charge. More than likely the center may ask for the money immediately or may bill, it is to their discretion. Once the insured has satisfied their Maximum OOP of $7,000 they do not owe any additional money towards covered expenses.

In situations such as the one your outlined, where there are going to be a considerable number of encounters and multiple expenses, there will more than likely be a situation where there may be an overpayment from the patient, which will require a refund from the carrier. For example, prior to hospitalization the facility requires a pre-payment of $7,000. The patient incurs $25,000 of expenses within the first few days and when discharged from the hospital is given a prescription for an expensive drug. There is a high probability that the hospital bill has not been submitted and adjudicated. The patient goes to the pharmacy believing they are in the 100% coverage, which they are, but the claim system does not yet show the hospital expenses. The pharmacy is told this and asks for the $250. This will need to be refunded by the plan.

Does this help?

 

[LostDollar]

No, the patient does not make the deductible payment while at the doctor’s office. The patient will pay according to the plan of benefits. If there is a $50 copay, they will pay that. If the office visit benefit is something along the lines of “Deductible+Coinsurance”, they will pay the full amount of the physician office visit, such as $500 if that is the cost.

What about "in-network" pricing adjustment? I have always expected the policy holder's office visit cost to be adjusted on an EOB if the provider is in network.

 

[LeeV]

What about "in-network" pricing adjustment? I have always expected the policy holder's office visit cost to be adjusted on an EOB if the provider is in network.

Yes, the EOB will show some fantasy-based cost, the fantasy-based discount, and then what the patient is being charged. If the group health plan has an office copay the insured will pay that amount. If the group health plan does not the provider office should ask for the in-network reimbursement amount, as required by their PPO contracts. If for some reason the provider asks for more than the in-network amount, and the patient pays it, the patient will need to submit a claim for reimbursement.

 

[renee15]

I'm trying to figure out how the 'payment for services' works when a Covered Med Patient has to pay a deductible, and copay before full coverage begins,...

'Who gets that money?'

EX.
Lets say Betty has been diagnosed with Cancer and has to see an Oncologist. Her out of pocket deductible is $5000 and her MOOP is $7500. --- Before the insurance pays 100% of her Dr. Visits and/or Treatments, she pays the copay and deductible.

• Does she pay it per Dr. Visit --- and this is applied towards her insurance deductible?
• Are all copays collected by the Dr. or -- do patients get billed by Ins. Co. ?

Thoughts /comments?

Thanks for your input!

Copay goes to provider. Deductibles are applied to outstanding charges, and insurance pays after deductible is met.

 

[Yagents]

The question is 'Does the doctor accept the deductible dollars from the patient' or 'does the patient send any 'Deductible money due' directly to the insurance company?

Like I mentioned above, if the deductible is 5k, does the patient make the deductible payment while at the Doctors office at her next visit (or does she give it to the insurance company) ?

LETS SAY the patient has 10 appointments scheduled with the Oncologist --- does she make 10 $500 payments to the doctor...or does she send that money to the insurance company?

NEXT; is this money credited towards Doctors Visit Charge ??? ---- (at this point the doctor wouldn't be reimbursed by insurance company UNTIL the entire deductible is met).

If copay, then patient pays dr the copay.

If subject to deductible, client should only pay network discounted price to Dr or get billed, which is best option