What you need to know about insurance and deductibles to better educate the patient


No matter how hard we try to assist and educate our patients there will alway be controversy. No one wants to pay medical bills when they feel they pay so much for health insurance. Patients often forget that they opted for cheaper insurance with higher deductible and coinsurance so they are shocked when they find out how much services will cost. As most of our patients procedures are elective in nature we will need to work to soften the blow.


It begins with the first encounter, when the patient makes their initial appointment or comes in for their office visit and asks insurance questions and OOP expense questions. When the patient asks is this covered by insurance, do not use the term “ it is covered by insurance “or“ your insurance pays for this service”. Instead tell the patient that we participate with their insurance. Explain to the patient that we participate/ are in network and will submit to their insurance company for payment, but all insurance policies are different regarding copays and deductibles. If they want to know their deductible met to date, copay and OOP we can assist them in getting this information, preferably prior to their appointment. This is a courtesy to them as most offices I have encountered have the patient check their benefits, OOP and deductible amounts.


Deductible is the amount of money the patient has to pay before the insurance starts paying on services. Not all procedures are subject to deductible though, in some cases the insurance company will pay the claim at the contracted amount with the patient only being responsible for a copay or coinsurance. This can be ascertained by calling the insurance company with the CPT codes and they can check for you if it will be applied to the deductible. Once the patient has met their deductible any additional services will be paid at the contracted rate with only a copay or coinsurance amount owed by the patient.


Copay refers to a negotiated rate that the patient pays for services, such as $40 office visit copay. The patient’s insurance card should give the amount of copay the patient is responsible for on a doctor’s visit. We are considered a specialist and this is listed on the card. Typically this is a higher amount than for primary care. Some insurance policies have a copay for procedures or ultrasounds. You will have to call the insurance company to get their specific plans policy.


Co-Insurance is the percentage of the approved amount of the service the patient is responsible for. So if we bill 1200.00 to the insurance company and they approve and pay 700.00 and the coinsurance is 10% then the patient will owe $70. This scenario is after deductible has been met. Coinsurance amounts (10% 30% etc) are frequently listed on the insurance card.


OOP is the amount of money for the patient’s applied deductible remaining , if any, and the percentage of the approved amount covered or any copay. So if patient has a remaining deductible of $300 and has a 20% co-insurance and the procedure is approved at $500 the patient is responsible for $340. ($300 plus 20% of the remaining $200).


With regards to vein patients, vein screenings are billed for an office visit in addition to the ultrasound. The ultrasound is not free and is a comprehensive exam as opposed to a simple screening exam. When patients have an ultrasound with either a referred vein screening and especially with a free vein screening we must be sure they know the ultrasound will be billed to the insurance and will be subject to deductible, copay or coinsurance.We can get OOP costs for vein procedures following the ultrasound and making the treatment plans.