Who gets to 'Keep the Deductible and Copays' --- Doctors or Ins. Co. ???

[rousemark]

The question is 'Does the doctor accept the deductible dollars from the patient' or 'does the patient send any 'Deductible money due' directly to the insurance company?

Like I mentioned above, if the deductible is 5k, does the patient make the deductible payment while at the Doctors office at her next visit (or does she give it to the insurance company) ?

LETS SAY the patient has 10 appointments scheduled with the Oncologist --- does she make 10 $500 payments to the doctor...or does she send that money to the insurance company?

NEXT; is this money credited towards Doctors Visit Charge ??? ---- (at this point the doctor wouldn't be reimbursed by insurance company UNTIL the entire deductible is met).

The patient pays all deductibles and copayments direct to the Dr.

 

[Mike Siegal]

To begin with, there can be a variety of scenarios because of how the providers may or may not act with respect to their billing procedures and the payments due. A few things first, to answer your questions.

No, the patient does not make the deductible payment while at the doctor's office. The patient will pay according to the plan of benefits. If there is a $50 copay, they will pay that. If the office visit benefit is something along the lines of "Deductible+Coinsurance", they will pay the full amount of the physician office visit, such as $500 if that is the cost.

No, the patient does not send any money to the insurance company in your question above.

The most common scenario is when a provider confirms eligibility and benefits with the plan. If the first provider is a physician's office and the plan has a copay, such as $25, they will charge the patient $25. That $25 goes against the MOOP. Let's assume a visit to an imaging center, where the cost is $1,000, again that office will verify eligibility and benefits. If the insured has not satisfied the deductible the imaging center will be told that. Based on your schedule of benefits and the earlier $25 copay, the insured will be responsible for the $1,000 charge. More than likely the center may ask for the money immediately or may bill, it is to their discretion. Once the insured has satisfied their Maximum OOP of $7,000 they do not owe any additional money towards covered expenses.

In situations such as the one your outlined, where there are going to be a considerable number of encounters and multiple expenses, there will more than likely be a situation where there may be an overpayment from the patient, which will require a refund from the carrier. For example, prior to hospitalization the facility requires a pre-payment of $7,000. The patient incurs $25,000 of expenses within the first few days and when discharged from the hospital is given a prescription for an expensive drug. There is a high probability that the hospital bill has not been submitted and adjudicated. The patient goes to the pharmacy believing they are in the 100% coverage, which they are, but the claim system does not yet show the hospital expenses. The pharmacy is told this and asks for the $250. This will need to be refunded by the plan.

Does this help?

So in my example, it looks like the 'Oncologist' would be the Specialist who collects the Deductible (in leu of services provided). THIS AMOUNT would be reported to the Ins. Company...

Thanks Lee

 

[rousemark]

So in my example, it looks like the 'Oncologist' would be the Specialist who collects the Deductible (in leu of services provided). THIS AMOUNT would be reported to the Ins. Company...

Thanks Lee

They don't have to report to the insurance company. They file the claim, the insurance company processes it, deducts any deductible or coinsurance from the payment amount and sends the remainder to the Dr. The Dr. Then bolls you for the balance. The providor might know up front what your responsibility will be and collect it at the time of service.

 

[LeeV]

So in my example, it looks like the 'Oncologist' would be the Specialist who collects the Deductible (in leu of services provided). THIS AMOUNT would be reported to the Ins. Company...

Thanks Lee

It depends on the plan of benefits for the insured. If the plan of benefits contains a Specialist Copay, then the insured will be responsible for that amount only. These copays tend to be in the $50-$100 range. In this scenario the Specialist will report to the insurance company the visit as well as the services used during that visit. This information is used to, among other things, calculate the payment to the Oncologist, application of any monies to the deductible and MOOP.

If the plan of benefits does not contain a Specialist Copay, then the insured will be responsible for a larger amount. The Specialist office will check for the insured's eligibility and benefits. If the insured has not satisfied their deductible and MOOP, they will be responsible for a larger amount which the Specialist will/should calculate for the insured and ask for that amount at time of service. Let's assume the insured has not had any expenses as of yet and nothing has been applied to the deductible. If the negotiated cost of services for that Specialist visit is $800, the insured will be responsible for that amount. Sometimes the medical office may offer to bill them, but most will now be asking for that payment up front.

Does this make sense and answer your questions?