Often patients (and sometimes providers of service) don't understand the terms used regarding insurance benefits. This can cause your patients to feel as tho they have been given incorrect information about the amounts they will owe you. Most often they will not return if they feel you have over charged them. Below is an explanation of what the insurance terms mean and how they apply to the patient's out of pocket amounts.
What is a Co-pay?
This is a specified dollar amount that a covered person is required to pay for certain covered expenses. The patient should pay this amount at the time of service.
What is a deductible?
This is the amount a covered person must pay for certain covered expenses in a calendar or plan year before insurance will begin paying benefits in that calendar year or plan year. Most often Co-pays do not apply toward satisfying the deductible. The patient should pay this amount at the time of service.
What is Coinsurance?
The amount a covered person must pay, calculated using a fixed percentage, for certain covered expenses. The patient should pay this amount at the time of service.
What is a Plan Benefit?
The amount payable for medically necessary treatments, services, and supplies that qualify for coverage under your policy.
What is Non-covered?
This means expenses not covered or in excess of policy benefits. The patient is responsible for paying this amount to the health care provider.
What is Out-of-Pocket?
The amount of the deductible and unpaid co-insurance that the covered person or their family must pay each calendar/plan year for covered expenses. Once this amount is met claims should process at 100% of allowed amounts with no additional patient amounts due on covered expenses.