Is Co-Pay Not Really what I Think?

Jan 28, 2016

  1. Suamere
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    Suamere New Member

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    I called up a prospectively-new PCP and asked if my Blue-Cross Blue-Shield was accepted.

    They said yes, and that Office Visits are $30 Co-Pay... Sounds right so far.

    I have had 4 very routine doctor visits in the past year. In addition, I had other Non-Routine visits and actions like removing a mole or whatnot. Nothing big. I paid extra for that sort of thing.

    A year later, and the xxxxxxx(edit: not hospital) Physician Group sends me a bill for $1,000... I call BCBS and they say that Co-Pay means I pay $30 at the time of the visit, but still have to pay the full Doctor Visit Amount later on. I was under the impression that Co-Pay means that's all you have to pay for regular doctor visits. My card says "Office-Visit Copay: $30"

    So is Co-Pay really just "Up-Front Pay", and everybody typically has to pay the full doctor visit cost in the end? If so, what's the point of Insurance covering office visits? The Office could have set me up a better payment plan at the desk when I checked in.

    If not... how do I deal with BCBS to get them to fix this bullsh#t
     
    Last edited: Jan 28, 2016
    Suamere, Jan 28, 2016
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  2. Yagents
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    Yagents Guru

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    You say routine visits, but then state the "hospital" sent you a bill. I'm confused.

    Anything done at a hospital will not fall under any "copay", and instead falls under your deductible which is probably at least $1000. Maybe for the mole?

    Your understanding of copays otherwise is accurate. But, you may find the plan you bought only came with 3 copays, and then the 4th doctor visit + is subject to the deductible.

    If not making headway, a quick email to whitehous.gov might just work.
     
    Yagents, Jan 28, 2016
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  3. Suamere
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    Suamere New Member

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    Thanks for the reply!

    Hospital was a poor choice of word. My PCP works for a Physician Group at the state college (OU). I receieved a bill from the Physician Group of OU, which covered 6 things... 4 visits, and 2 other activities. I paid for the 2 activities, and I paid $30 Copay at the beginning of each of the 4 visits. The new bill I received, and the result of a conversation with BCBS, states that I now have to pay ~$250 in "Established-Patient Visit" fees for each of the four visits.

    The OU Physicians Group Billing department tells me these are just typical Visit Fees. BCBS says the same thing, but says the $30 Copay is just an up-front fee, and that I still have to pay the entirity of the visit fee in a later bill.

    Is it possible that the plan I chose actually does NOT pay for Office Visits? If so, why is there even the facade of a $30 Copay?
     
    Suamere, Jan 28, 2016
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  4. Yagents
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    Yagents Guru

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    Did you buy the insurance through the school?

    If so, all bets are off as none of us will know the details of the plan, and each school plan is built differently.
     
    Yagents, Jan 28, 2016
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  5. Josh
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    Josh Retired Agent, Current List Broker

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    Usually if you see a provider you are responsible for the bill. Generally if you have insurance with a copay then the copay is what you would pay, the insurance pays the rest. That said, if the insurance declines the bill for whatever reason, then they go back on you for the bill.

    The removal of a mole and an office visit can be two different things too. It's possible you paid the copay for a routine office visit, but because there was a minor surgery and/or other service performed, it was billed differently and so it fits under a different copay/coinsurance amount.

    It's going to sound boring, but you might want to actually review your coverage and see exactly what they were billing for and that might shed some light on it.
     
    Josh, Jan 28, 2016
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  6. Alston
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    Alston Guru

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    You may be paying a facility charge.

    In my opinion a facility charge is appropriately charged when you go the hospital or some facility that has expensive equipment. Even if you only have a simple exam or procedure done that requires no fancy equipment, they still need to bill you more because they have serious overhead.

    So it makes sense to go to your PCP's office for simple procedures so that you don't get charged the facility charge. Right?

    However, I think the hospitals recently found a loophole in he law. Hospitals are buying up practices, not adding any fancy equipment to the office but are still tacking on the facility charge.

    So you may pay a facility charge at what looks like an ordinary family doctor's office simply because, unbeknownst to you, the practice is owned by the hospital.

    Nice huh? What a country.
     
    Last edited: Jan 28, 2016
    Alston, Jan 28, 2016
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  7. Suamere
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    Suamere New Member

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    Thanks for the replies. No, I am not a student of the school. The OU Physicians is a major health care providing facility in Oklahoma.

    The bill says:

    Established Patient - Level 4 . . . $245
    Drainage of Abscess: $293
    Patient-Paid Co-Pay: $30
    Patient Payment: $293
    Insurance PPO Payment: $215
    Insurance Adjustment: -$215
    Total Owed: $215

    So it was actually paid for before, but they adjusted and changed their minds.
     
    Suamere, Jan 28, 2016
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  8. unic.consulting
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    unic.consulting Guru

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    Did the insurance company explain why they made the adjustment? Normally they will contact the patient to let them know.

    I have come across several cases where the insurance company had sent a letter to the patient asking to verify information. The patients did not send back the information (thought it was junk mail) and the insurance company went back and took their money back from the doctor's office.
     
  9. FLM2
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    It's pretty simple-your copay most likely covers what is known as history and exam and all other services are subject to the deductible, that's why a balance remained after the copay. Insurance companies have different definitions of the term 'copay', some cover everything in the office, others just history and exam-without knowing whose plan it is it's impossible for anyone to give you a 100% accurate answer.
     
    FLM2, Jan 28, 2016
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  10. AllenChicago
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    AllenChicago Guru

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    100% Perfect Succinct Accurate Answer, FLM2! Back when people had control over their own health insurance coverage level, we advised steering clear of "co-pay" plans. The increased premium didn't justify the benefit of having these loosely defined Co-Pays..unless they went to the doctor every month.

    But if they went to the doctor every month, underwriting would turn them down anyway. End result: VERY few co-pay plans were sold back when the consumer was in control.**

    **The above is personal experience. Your results were probably different.
     
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