First, it is imperative that you understand everything about your insurance policy. The ins, the outs, the deductibles, the co-pays, the co-insurance... everything. Many times I realize when patients come to our office they are completely clueless as to how their insurance works. For instance, most of the time only a routine annual physical exam is covered at 100% for insurance purposes. Even then, the annual labs that go along with that routine physical may not be covered. Therefore, the OFFICE VISIT is covered, but the annual labs that go along with this visit may not be. However it is impossible for the physician most times to be able to tell you how much these labs would cost. These are questions that you should ask your insurance company prior to having them drawn. Please bear in mind that at a lot of doctors offices, if you go in for an annual physical yet have a complaint or concern that needs to be further assessed, the physician many times will not bill a routine physical. Instead, they will bill an "office visit" which again may be subject to the deductible or co-pay, etc. You should clarify with the office staff prior to live leaving what will be billed. Also, do not forget that there are different "rates" for families and individual policies!
Next, you should know whether you have co-payments or co-insurance. There is a big difference between the two. Most of the time, if you have a co-payment you do not have a deductible for office visits. If you have co-insurance you usually do have a deductible for office visits. For instance if on your card it says that a family medicine doctor is subject to $20 copay, you can bet that every time you go to the doctor you will pay $20 and usually nothing else unless additional studies were ordered. If you have a co-insurance you are usually subject to a certain deductible prior to the co-insurance before any coverage by the insurance will take place. After that deductible is met you may be subject to what is called co-insurance. For example, let's say you have a $1000 dollar deductible for the year which you have already met. You go to see a doctor and the office visit is $100 (this number, again is not a random number, it is what the insurance company has contracted with the doctor and can vary greatly). Since your deductible was met, you will be subject to the 20% co-insurance for the contracted rate of $100, thus, you will owe $20. Make sense?
Finally, WHERE these tests are done is very important. Going back to contracted rates, usually any tests done inside the walls of a hospital will cost much more money than ones that are at an outpatient facility. For instance, I own an ultrasound machine in my office. Many times I have to order ultrasounds of the thyroid gland or the abdomen. Having these tests done in my office cost a lot less money than having these tests done in the hospital. Why? Because the hospital has a higher contracted rate of reimbursement with the insurance company than I do. Therefore the same test done in my office cost $150 were in the hospital and they cost upwards of $300-$400. Even more important, the costs vary from one hospital to another, so IF you are subject to a deductible, shop around! So, you should always try and have diagnostic test done at an outpatient facility or in a doctors office. I not only do ultrasound in my office to help with my reimbursement, and also help save my patients money.
Now, you must realize that these numbers usually do vary greatly for office visits and diagnostic testing (labs, x-rays, CT scans, etc). So, just because you have copay meant for office visits does not mean that you were have call payment for diagnostic test. Many times diagnostic testing is subject to deductible and co insurance. Again you should know your own individual policies so you can be more aware of how to save yourself money.
I hope this helps, and I would be more than happy to answer any questions...if I know the answer!
Until next time.....