Friday Five Sample

Every Friday, we will review your questions and answer them here. Here are some sample questions and answers.

A: This could be for many reasons, so I’ll name a couple:

  1. They never recorded your payment and therefore don’t show record of it. If you pay with cash, get a receipt—that way, you have proof for them to post!
  2. I’m going to assume that this was paid at a doctor’s office. Co-pays are only for the actual office visit (cpt codes 99211-99215, 99201-99205), so, if anything else was done, you may have additional costs, outside your copay.

A: A co-pay is a fixed amount that is paid for specific services, such as $20 for any primary care visit, $150 for an emergency room visit—the price is fixed.  Co-insurance is a percent and is not fixed.  Let’s say that your policy is 80/20 co-insurance for primary care.  Your insurance company allowed $100 on a $200 visit charge.  Your insurance will pay $80 of the $100, and you will pay the remaining $20.  It’s normally not totally even numbers like this, this was just to make it easy to understand.  You pay a percent of the amount allowed by your insurance company.  One is fixed (co-pay) and one is a percent (co-insurance) of the amount allowed.

A: Great question, and it’s a tough one!  First, you must keep track of what the provider of service did.  Then, request a copy of your record for the day, the bill that was submitted to insurance, and the patient statement you received.  Compare them and see if anything looks out of the ordinary.  Unless you understand coding and billing, it will be hard to determine the accuracy.  Check out our services section if you want additional help.

A:  Check out the blog post about contracted versus non-contracted—it explains this in detail.  In-network means that your provider has contracted with your insurance company to accept a specific rate for services provided.  Out-of-network, which is also a non-contracted provider, means that they can charge you whatever they want, and you will be responsible for that amount unless you negotiate up-front to pay a different amount.

A: First and foremost, I would NOT ask the provider of service.  Why, you may ask? Because, there are many policy types within one plan ,and yours may be one they aren’t contracted to do business with.  Always go by what your insurance carrier has available, so use their portal or call them on the phone and ask.  Write down the name of the person you spoke with and ask if there is a reference number for the call.  You’ll do this just in case they give you wrong information. Should the claim be denied due to the provider not being in-network, it’s great leverage for an appeal.

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