Billing Terms You Should Know
-
1
Co-pay
Co-pay
A co-pay is the flat fee determined by your insurance company that you pay each time you receive medical care, usually between $10 and $50. Although WHA is what’s called a “specialist” practice (as opposed to primary care), co-pays are determined by your insurance company and many insurance companies require only a primary care co-pay for certain types of visits, such as women’s wellness visits. If you pay a primary care co-pay in our office when your insurance company requires a specialist co-pay, we may bill you for the difference.
-
2
Co-insurance
Co-insurance
Co-insurance is the percentage of your medical bills that you have to pay, typically after you’ve paid your deductible. Usually you will be required to pay the co-insurance amount up to the point where you have satisfied your plan’s out-of-pocket maximum. If you have questions about the portion your insurance company has paid and why you owe what you do, the best answer will come from them. If you have questions about what we have charged and why, give us a call!
-
3
Deductible
Deductible
A deductible is the amount you must reach before your insurance company starts paying for care. There are situations where you’ve reached your deductible but are still responsible for a portion of your bill; this could be because your insurance company applied WHA’s charge partially to the deductible, leaving you with a portion of the bills—or even if your deductible has been completely reached, you may still have a coinsurance amount until your out-of-pocket maximum is reached. If you have questions, contact your insurance company for a complete explanation.
-
4
Out-of-Network
Out-of-Network
Out-of-network describes providers and facilities that haven’t signed a contract with your health plan. Your health insurance plan is required to tell you, on their website or at your request, which providers, hospitals and facilities are in their networks. Hospitals, surgical facilities and providers must tell you which provider networks they participate in on their website or on request. It is always a good idea to check to make sure the doctor and facility you wish to receive care at is part of your health plan’s network before scheduling.
-
5
Balance Billing
Balance Billing
There are certain situations where out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
-
6
Surprise Billing
Surprise Billing
Surprise billing is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. In these situations, you are protected against surprise billing. Learn more >