What does your patient pay when they have co-insurance?
The Profitable Path: Maximizing Co-Insurance Collections for Providers
When a patient arrives at the (DOS) date of service, the primary question for the patient’s insurance is whether they have a co-payment or deductible. The co-insurance is a percent of the “allowed” rate that a patient pays at the time of service (DOS). Most plans have a patient pay out-of-pocket expenses or the co-insurance after the patient has obtained their deductible. A few insurance plans after a deductible that does not apply, and the patient only pays a co-insurance. Please Verify the Patient’s Insurance Benefits to know.
How much does a patient pay when they have co-insurance?
When a patient arrives at the (DOS) date of service, the primary question for the patient’s insurance is whether they have a co-payment or deductible. The co-insurance is a percent of the “allowed” rate that a patient pays at the time of service (DOS).
Most plans have a patient pay out-of-pocket expense of the co-insurance after the patient has obtained their deductible. A few plans after a deductible that does not apply, and the patient only pays a co-insurance. Please Verify the Patient’s Insurance Benefits to know.
How much does a patient pay when they have co-insurance?
The co-insurance is a percentage of the “allowed” rate that is to be paid for each service. Example: 90834 has an “allowed” rate of $100
What does the Provider collect directly from the patient?
Example:
90834 has an “allowed” rate of $100
Co-insurance of 25%
When the patient has not obtained their deductible
–The patient will pay out-of-pocket $100, co-insurance does not apply
The patient has obtained their deductible
-With co-insurance of 25%, the patient will pay out-of-pocket $25.00
The patient has obtained their out-of-pocket maximum
-The patient will pay $0.00, co-insurance does not apply
How much does insurance pay as reimbursement?
Example:
90834 has an “allowed” rate of $100
Co-insurance of 25%
When the patient has not obtained their deductible
-The insurance will pay $0.00
The patient has obtained their deductible
-With co-insurance of 25%, insurance will pay the remainder of $75.00
The patient has obtained their out-of-pocket maximum
-Insurance will pay $100.00, co-insurance does not apply
Does the “Allowed” rate apply if the provider is credentialed with insurance
Yes, when a provider completes all the paperwork to be credentialed or paneled with an insurance company, they agree to charge the insurance company members the agreed-upon rate for their geographical area.
Does the “Allowed” rate apply if the provider is non-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 claims to insurance, the “allowed” amount is not applicable. The patient will be subject to the provider’s bill rate at the time of service.
Patient responsibility terms for out-of-pocket payment
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
Co-insurance – Select to see the blog page
-See YouTube video in Spanish- Cuando su paciente tiene un “Co-seguro”
Coordination of Benefits
-See the YouTube video in Spanish “Coordination de Beneficios”
Out-of-pocket maximum – Select to see the blog page
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