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Ever wonder why after paying a copay to your medical provider you’re still responsible for a substantially sized bill? You’re not alone. Healthcare coverage in America can be incredibly confusing, as well as expensive. We’re here to help simplify understanding insurance coverage for you so you won’t be as surprised with additional costs after your next healthcare visit.

First things first, take time to find a healthcare provider within your insurance network to avoid additional out-of-pocket expenses. Upon arrival to an in-network healthcare provider, show your id card to the front desk and pay any copay associated with that particular visit. Copay amounts should be listed on the front of your insurance card.

Here’s a look at what goes on behind the scenes after your medical visit between your healthcare provider and insurance company:

  1. After your visit, your healthcare provider will file a claim with your insurance detailing the care received during your visit.
  2. Your insurance provider will review the claim and determine the allowed amount, or the cost, of your visit.
  3. Your insurance provider will send a summary to the healthcare provider explaining how much they will pay, and how much you owe on the claim. You will also be sent an Explanation of Benefits.
  4. Your healthcare provider will review the claim sent by your insurance company and wait for payment from your insurance company.
  5. Your healthcare provider will then send you a bill that you are responsible for paying, which will go towards your deductible or coinsurance.
  6. Make sure you look over the Explanation of Benefits sent from your insurance as well as the bill sent by your healthcare provider to identify any discrepancies. If the documents don’t match up, contact both your insurance and doctor’s office for more details.
  7. Pay the portion of the bill you are responsible for directly to your healthcare provider by the specified due date. Many healthcare providers will work with you on payment plans if you can’t pay the entire bill at once.

Important health insurance terms to know:

In-Network Provider– A healthcare provider contracted with your health insurance company which provides services to plan members for specific pre-negotiated rates.

Copay- A flat fee you pay for a medical service. Common copays include visits to your Primary Doctor, a Specialist, and the Emergency Room.

Claim- A formal request from your healthcare provider to your insurance company asking for payment based on the terms of your insurance policy.

Allowed Amount- The maximum amount a plan will pay for a covered health care service.

Out-of-Pocket Expenses- The maximum amount you pay yearly for eligible medical care covered by your health plan. Each plan varies significantly.

Explanation of Benefits- A statement by your health insurance company explaining the medical treatments or services that were paid for on their behalf.

Deductible- The amount you for pay for medical care each year before your plan begins to pay.

CoinsuranceThe percentage of costs of a covered health care service you are still responsible for after you’ve paid your deductible.

We know you likely still have more questions about health insurance and billing, please know that we’re happy to answer them! Just walk in or schedule an appointment online at your local Our Urgent Care and we’ll be sure to help you with any questions you may have.