I paid for my office visit, why am I getting another bill?

Many people do not understand how health insurance works. They are puzzled when the get a bill from a office visit or hospital when they thought they paid their part. Insurance claims can be complicated and many times the doctor has made an error in coding, which can make all the difference in what the insurance company pays.

So you paid your copay when you went to the doctor and now youre wandering why you are getting a bill from that visit. Well if the bill is for lab or x-rays, then that is because typically these procedures are not covered under the copay. Many people do not understand this.

It all comes down to how the visit is coded as well when your doctor send in the claim to your insurance company. An office visit can be coded at 5 different levels and this is what a copay usually covers. Any other code usually falls under the deductible portion of health insurance, which we will discuss later.

If you have a procedure, lab or x-ray done during an office visit that does not fall under the office visit copay then the additional charges incurred are subject to deductible and co insurance status at the time of services.

If at the time of services you have not meet your deductible then you are responsible for the total charges until you have paid that deductible amount out of pocket for the year. If you used a in network provider or facility you will be charged a negotiated rate.

If your deductible has been meet, but you have co insurance also then you will also be expected to pay a portion of the charges. Lets say you have a 80/20 co insurance. Well then you will have to pay 20% of charges (20% of the negotiated charges if using in network provider) until your co insurance max. has been satisfied.

You need to know if your insurance company goes by calendar year or anniversary date. This makes a huge difference and is reason for much confusion for many. If they go by calendar year then no matter your time of policy purchase everything (deductible and co insurance ) will start over on January 1st.

One of the most confused subjects of health insurance claims is Preventative exams. Most plans cover them with limits. Usually one per year and only certain test are included. There may also be a monetary limit such as $300. If you go in for a physical, but your doctor ends up treating an illness, be sure your doctors office codes the visit as office visit instead of your annual preventative exam.