Dealing with insurance can be tricky. This should help clear the air.

The Process

Health insurance plans are all different, so make sure to become familiar with yours. Each insurance plan has in-network and out-of-network providers. Only in-network providers will accept your insurance. Out-of-network providers are not contracted with your insurance company, and therefore may require you to pay the entire bill out of pocket unless you have out-of-network benefits which may pay a portion of the cost. Once you visit your healthcare provider, you will either pay a copay or not, depending on your plan. Doctors cannot waive this fee; they are contractually obligated to collect this.

After your visit, you will receive an Explanation of Benefits (EOB). This is not a bill, even though it will have a cost listed. This is a breakdown of the charges your healthcare provider charged your insurance company for services rendered, how much your policy covered, and the balance your provider must bill you. The EOB will be followed by a statement from your provider. It is common for offices to check the benefits and eligibility of the patient before seeing them in order to assist the patient with planning ahead, but this is a courtesy, not an obligatory requirement.  It is still recommended that you familiarize yourself with your specific benefits to avoid surprises.

Your Explanation of Benefits (EOB)

An explanation of benefit is an overview of the claims processed by your insurance company.  It is important to understand the detailed claim and benefit information on these forms.  The amount billed is the total amount that the provider billed for the provided services.  The discount is the difference between the amount charged by the provider and the contracted rate between the provider and your insurance.  This is not a true discount but rather an adjustment that your provider is required to make based on the overall charges and the contractual rates with your insurance.  The amount your plan paid is the contracted rate between the provider or facility and the insurance.  The total you owe is the portion of the amount billed that you owe the provider.  This amount includes your deductible, co-pay, co-insurance and non-covered charges.  Any charges that have been disclosed to you as non-covered may or may not be included in this amount.

How Cost is Determined

Every visit and procedure type are assigned a code or codes, and each has a cost value associated with them. Every office may charge differently, but each office can only collect the value contracted between the insurance and the provider. If a copay is required, this is because the insurance company is requiring one from the patient. The healthcare provider is bound by the insurance company to collect copays at the time of the visit. For patients with deductibles that are not met, most clinics (including ours) require a partial payment toward the deductible at the time of service. Around the time the insurance company agrees to pay, they send the EOB to the patient and the provider, and then the patient is billed for the difference by the provider.

Doctor Responsibility

Doctors are not included in decisions of how much insurance will cover. This is entirely based upon individual plans offered by employers in most cases and chosen by the patient/employee. Every doctor may create their own prices for services, but will never receive more than the contracted rate. It is the doctor’s responsibility to maintain consistency for all patients. Fees may not be waived for some and not for others.

Patient Responsibility

It is your responsibility to know your plan. There are online resources, personal online profiles, and even apps for insurance companies which will explain how your coverage works. There is a customer service phone number on the back of every insurance card identifying insurance representatives ready to answer any questions you might have about your specific plan.  If you speak to an insurance representative, be sure to document your discussion well and obtain a name, date and time called and a reference number for the call.  If you have any questions about charges from a provider, consult your Explanation of Benefits, which may be available in your online profile. It is up to the patient to determine which provider is in-network in order to avoid unexpected or unwanted costs.

We’re Here to Help

Understanding how costs are generated and applied to you may be confusing, so consult your insurance plan. If you still have questions, Dr. Wendt and her team are very knowledgeable and may be able to help. They make every attempt to obtain current insurance benefits and eligibility information to advocate on your behalf.  When they discuss it with you, ask lots of questions so you have a full understanding.  They are well aware of how confusing and complicated insurance plans can be.  Call and make an appointment to address your allergy and asthma needs and come into your appointment more confident about what to expect from your insurance coverage.

Relieve Allergy Asthma & Hives is located near Kierland Commons, Scottsdale Quarter, DC Ranch and Grayhawk at 21803 N. Scottsdale Road Ste. 200, on the corners of Deer Valley and Scottsdale Roads, and has convenient evening and early morning hours to accommodate your schedule.

Dr. Wendt is also available for telemedicine appointments as appropriate. Insurance plans accepted. Call 480-500-1902 today to schedule an appointment and begin your allergy testing and treatment with Dr. Wendt at Relieve Allergy, Asthma & Hives in Scottsdale, Arizona.

Learn more about Dr. Wendt and Relieve Allergy Asthma & Hives at www.relieveallergyaz.com and FOLLOW US on Instagram, Twitter, Facebook, and Linked In.

REFERENCES

  1. Out-of-Pocket Health Costs: Copays, Coinsurance & Deductibles. Retrieved 20 January 2020, from https://www.nerdwallet.com/blog/health/copay-vs-coinsurance/