Written by Richard Lander, MD
Insurance coverage in the 21st century can be confusing . It is not always easy to discern what you owe your doctor or why it is owed. It is often confusing for you the consumer and even at times for the doctor’s office. Some families pay their monthly premiums directly to the insurance company while others pay through their employer.
The amount owed is dependent on your employment contract.
Many years ago employers paid the entire amount of a health insurance policy however, in today’s economy, more and more employers are shifting a portion of the health care costs to their employees.
While some look at the escalating cost of medical care and point the finger of blame at doctors, and hospitals and the cost of medication, one need only look at the ever increasing profits of the insurance company to find the true culprits.
According to the New York Times in February 2012, one large national insurance company posted a 73% increase in profits.
Many American families are feeling the pinch of the ever increasing cost of healthcare. Therefore when you have paid the co-pay at the time of the office visit and you receive a bill stating you still owe money, there is disbelief. Depending on your individual insurance policy you might have a deductible before the insurance company will pay any benefits. This is typically seen in the beginning of the calendar year. Another possibility is that your insurance policy might cover a percentage of the charges leaving the balance for you to pay.
It is also possible that your policy does not cover a specific office visit or procedure and you are responsible for the payment. An example of this might be a breathing test performed in the doctor’s office. Your policy might cover this if and when given at the hospital but not at the doctor’s office. It might be a rapid strep test which is not covered. Occasionally a policy might exclude well visits or only cover one every other year.
It is your employer who has chosen what benefits to cover, not your doctor.
It is important to know the details of your individual insurance policy so that you know its limitations. Your doctor does not have this information. Once you receive a non-covered service you then take on the financial obligation for that service. So make it your business to know the details ahead of time. It will avoid a lot of pain and misunderstanding if you do.
Then when you receive a bill from your doctor, you will know not to discard it and assume it is a mistake because you know you paid your co-pay. Call the doctor’s office and discuss it.
Dr. Lander has been practicing pediatrics for 32 years in New Jersey and is the immediate past chairman of the American Academy of Pediatrics Section on Administration and Practice Management. He says if he had to do it all over again he wouldn’t hesitate to be a pediatrician.