What does your patient pay when they have a Co-payment

When a patient arrives at the (DOS) service date, the primary question for the patient’s insurance is whether they have a co-payment or deductible?   When a patient has a co-pay or co-payment with their insurance, it’s straightforward.  An example of a copay is $25.00

What does the Provider collect directly from the patient?

At the time of service, the patient will pay out-of-pocket $25.00.  Insurance will pay the remaining amount, totaling the “allowed” amount or rate.

Payments for the provider for reimbursement

For example, the “allowed” rate for 90834 is $100.00

In the example, the patient has a co-payment of $25

• The patient will pay out-of-pocket $25 for co-payment
• Insurance will pay $75
• The provider will receive the total reimbursement of $100.00

When will insurance reimburse 100% of the service?

When the patient reaches the Out-of-Pocket Maximum (OOP)

• Insurance will be 100% for all qualified services
• The patient will pay $0.00 out-of-pocket
• It’s essential to verify the benefits when a patient has reached the status of reaching their Out-of-Pocket Maximum (OOP)
• This ends at the end of the policy year.  Many policies end on December 31st of the year.  The deductible will reset back to 0.00 at the beginning of the new policy year, meaning the patient will need to pay out-of-pocket for services.

Does the “co-pay” matter whether the provider is Credentialed with insurance?

Yes, most insurance policies have different out-of-pocket requirements for policyholders based on the network status of the provider that renders the service.

Does the  “Allowed” rate apply if the provider is credentialed with insurance

Yes, as a non-credentialed provider, insurance will apply a maximum that will allow for each service code submitted to insurance.  If the provider does not submit the insurance claims, the “allowed” amount is not applicable.  The patient will be subject to the provider’s bill rate at the time of service.

Patient responsibility for out-of-pocket

• Co-payment –  Select to see the blog page
  • See the YouTube video in Spanish  “Copago”
• Deductible –  Select to see the blog page
  • See the YouTube video in Spanish Cuando su paciente tiene un “Deducible”
• Co-insurance –  Select to see the blog page
  • See the YouTube video in Spanish “Cuando su paciente tiene un “Co-seguro”
• Coordination of Benefits –  Select to see the blog page
  • See the YouTube video in Spanish “Coordinación de Beneficios
  • ”Out-of-pocket maximum –  Select to see the blog page

Provider Reimbursement

• Verifying the patient’s insurance benefits –  Select to see the blog page
• Credentialed or paneled with insurance
• Non-Credentialed or non-paneled with insurance
• “Allowed” amount or “Allowed” rate with insurance
  • See the YouTube video in Spanish “Tarifa Permitida”
• When my patient has a deductible, what do I collect from the patient?