No deductible, but out of pocket. Please advise

[Lauwren86]

I am fairly new to the medical billing and insurance field and I'm running into an issue on deductibles vs out of pocket and how to explain this to my boss.
Essentially, we have a patient who came in with no deductible, but a $3,500 OOP. His coverage is 100% with a $40 copay, every service being offered at our facility is applied to the OOP.
Does this mean that basically his OOP is almost functioning as both deductible and OOP in that he will not be covered until his OOP is met, and then once it is met, he will not be responsible for anything else, and will be covered at 100%? Or is it that his insurance will pay 100% right off the bat, but once his OOP is hit, he won't be responsible for any copays? Or is it something entirely different?
Anyone who can explain this to me, the help would be greatly appreciated. As I said, I'm fairly new to this and was not properly trained so I am learning as I go and want to ensure that I'm handling this correctly.
Thank you!

 

[leevena]

There could be a variety of answers, there is not enough info made available.

Off the top of my head I would say that it is highly improbable that this person has a OOP of $3,500 and no deductible. Possible, but highly unlikely. What is more probable is; 1) the benefits have an office copay of $40 and other expenses are subject to the OOP %, or 2) the benefits have an office copay and other expenses are subject to deductible and OOP.

Short of you providing a copy of the benefit schedule, it will be difficult to answer.

 

[rcduggan]

not sure how this found its way to General Insurance Agent discussion but it doesn't belong here. i'd advise you call the insurance company yourself and have them explain the SBC to you and your boss.

 

[Yagents]

Deductible is first phase where client pays 100% of the deductible.

Coinsurance is the next phase and can be 60-100%. In this case its 100% which means insurance company pays 100% after deductible. If 80%, then ins co pays 80 and client pays 20% up to a certain amount, say $2000. The deductible plus coinsurance equals the OOP out of pocket maximum.

Copays can come before or after the deductible, same for rx copays. Typically, they come before. Copays may or may not go towards OOP

But, the prior advice was right. Every plan is different, and u must get summary of benefits to make sure