r/HealthInsurance • u/fauxkatan • 1d ago
Claims/Providers I need to verify how copays work
I have a provider who is new to owning their own practice so I’m wanting to confirm. I tried calling my insurance but I was unable to articulate my issue. Let’s hope I do better here
The person is in network for an insurance company who notoriously pays low.
They have their visit cost and I have a 10% copay for in network, they are in network.
I will put the amounts but if my provider reads this I’m just trying to make sure we don’t screw up.
Visit is $104 EOB says will pay $62.10 Says discount is $35 Total due from patient is $6.90
Provider wants copay to be an even $35 so that they get the entirety of what they billed. I was under the impression that the amount owed is all they can bill.
I personally wish I could pay this person that amount but I believe it may be against terms and conditions for the company they are billing.
Can anyone shed any light? Also please feel free to ask questions if I have explained things wrong. I also hope I picked the right flair.
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u/SupermarketSad7504 1d ago
What you have described is a percentage % and it's a coinsurance. Not a copay. Copays are flat dollar amounts. Example allowed is $62.00, you pay $35 copay and insurance pays $27.00. You have detailed coinsurance which is 10% of the allowed rates up to your maximum out-of-pocket. Then the insurance pays 100% of the allowed. Your doctor seems unclear on the fact that his billed rate is not equal to the allowed. He may have been part of a larger practice that was able to get more money in the past.
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u/Big_Two6049 1d ago
In network means they have to accept what the eob and their contract states. They cannot balance bill you past your copay. If they want to do that, they have to leave the network and check if out of network benefits are available.
This is pretty basic stuff they should know.
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u/fauxkatan 1d ago
This is what I thought. And if they do try to balance bill they could risk their standing with the insurance company.
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u/Big_Two6049 1d ago
Standing with insurance company means nothing but they can be sued by them.
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u/fauxkatan 1d ago
Thank you for the help. I really didn’t want to force the issue until I was sure I knew what I was talking about.
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u/Big_Two6049 1d ago
Just tell them to check with the insurance company as they informed you your total financial responsibility is listed on your eob. If that doesn’t make financial sense to them, they can leave the network and balance bill patients as they see fit.
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u/CartographerKey7237 18h ago
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u/CartographerKey7237 18h ago
Sounds like coinsurance as someone else said. EOB says 10% owed. That's all if pay and give provider eob to show your liable portion.
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