Medical Billing & Insurance Explained

Medical billing. Nobody likes it. Nobody understands it. It’s confusing and complicated. But we are here to answer your questions and educate you on how it works. Knowledge is power! If you understand the process, maybe you’ll feel a little better about your bill. So let’s get to it!

Understanding insurance costs

The first thing to understand is that we don’t set prices for anything covered by insurance. Your insurance company does. Here’s how it works. We approach an insurance company and say, “We would like to see your customers.” The insurance company may say, “Sorry we’re not taking on any new doctors.” In which case, we would then be “out of network” for that insurance carrier.
If they say, “Yes, we would love to have you serve our customers,” then they send us a contract. In the contract, all the prices for every medical procedure and service are dictated.

Each insurance company has their own contract with their own terms and prices.

As a result, the cost of the same procedure can vary greatly patient to patient. It all depends on which insurance carrier you have and their contract. The bottom line is that prices are dictated by your insurance carrier. If we submit your claim to your insurance company, we are not allowed to charge you anything different (more or less) than what the contract says.

Please note that if you do not have insurance, we are still able to see you as a patient. We would be happy to quote you the “self pay price” for an office visit or a particular procedure upon request.

Copays, coinsurance, deductibles, oh my!

A copay is a flat fee you pay on the spot when you visit the doctor. It is important to note that the copay may or may not cover your entire bill for your visit. Often it does not, so don’t be surprised if you still receive a bill after your visit.

Your deductible is an amount of money you pay each year for medical services before your insurance kicks in and starts paying. One item that often does not count toward your deductible is copays.

Coinsurance is the portion of your medical costs that you pay after your deductible has been met and your insurance kicks in.

For example, if your coinsurance is 20%, then after your deductible is met, you would pay 20% of a medical bill and your insurance company would pay the remaining 80%.

Out of pocket maximum is the maximum amount of money you can pay for medical services in a given year. If you reach that amount, your insurance will cover 100% of medical expenses thereafter.

Why can’t you tell me what I owe at the time of my visit?

Mostly because of the stuff in the last section. When you come for an appointment, we document what was done and send that information to your insurance company. They verify that the service is covered and they calculate the bill for the visit based on the prices that they set forth in the contract with our practice.

Then they check if you have met your deductible and if you have met your out of pocket maximum.

Based on this information, they calculate how much they will cover and how much you will pay. What you owe for a visit can vary drastically depending on if your deductible and/or out of pocket maximum have been met. Only the insurance company has all the most current information about your deductible, coinsurance, out of pocket max, etc. That is why they verify and determine your final bill and not us.

Wait, does my insurance cover this?

Great question! A lot of people do not have a good grasp regarding what is covered and what isn’t. It’s really simple. If it is deemed medically necessary by your particular insurance company, it’s covered. Otherwise, it is not. It is important to note, that what is medically necessary may sometimes differ from one insurance company to the next. If we are unsure whether a procedure will be covered, we can check with your insurance company prior to performing the procedure.

Cosmetic procedures do not meet the definition of medically necessary and therefore, are not covered by insurance.

Sometimes, patients want a spot removed that doesn’t pose a threat to their health. Because these spots are benign, insurance considers their removal to be cosmetic and will not pay for the procedure. That does not mean the spot cannot be removed, it simply means that the cost of removal will be the patient’s responsibility. Your doctor will discuss with you whether or not a procedure is likely to be covered by insurance and will give you the option of cosmetic removal. All cosmetic costs will be discussed with you and agreed upon prior to the procedure.

Contact Us Today

About the Doctors