Medical Billing Information

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Understanding Insurance Coverage & Copayments

It is helpful to be knowledgeable of and understand your insurance coverage and what the out-of-pocket expenses will likely be when you go for an appointment. In addition, knowing this information will make understanding the charges easier when the bill arrives. Given the growing number of health plan requirements, coverage issues, and varying copayments, contact your insurance company if you have questions as to your level of coverage and what copayments, coinsurances and deductibles may be your responsibility. When it comes to copayments, keep in mind:

  • Some insurance companies have policies that include a copayment for a physician's visit and additional copayment(s) for lab or radiology services performed in a doctor's office, even if these services are performed on the same day. There is various levels of coverage according to the reason for the lab work or visit.  Often lab work ordered by the physician at your annual exam will have a patient liability as the physician orders the blood work for clinical reasons.  If you present to your physical exam with acute or chronic symptoms and your physician evaluates those symptoms there may be an additional charge to your insurance plan for that.
  • Most insurance companies have policies that include different co-payments for physicians of different specialties. For example, a visit with your primary care physician may be a $10.00 copayment and a visit with your orthopedic physician may be a copayment of $20.00.
  • Your clinician may invite another clinician to consult on your case. If the consulting clinician provides a telephone consult or comes to the exam room to see you, he/she will submit a bill to your insurance company for his/her services. Thus, you may receive a bill according to your insurance plan's out-of-pocket expenses.
  • Coverage for eye exams varies according to health plan and employer.  It is important that you know what your coverage is for eye exams and the preferred locations for eye exams.  Your insurance company can provide that information.