Many patients are surprised to receive a bill after their visit if they don't have any copay, or they already paying a copay at the time of their appointment. It’s a common point of confusion and an important one to clear up.

Here’s why this happens and what it means for you.

What Is a Copay?

Some plans have a copay, others do not. A copay is a fixed amount you pay upfront when you visit a healthcare provider. It’s set by your insurance plan and doesn't necessarily mean it fully covers any part of your visit. It's the minimum amount you might owe as the patient, but it's usually not the full amount you will owe.

Visits are billed to your insurance after completion, and depending on what was done during the visit and what your plan coverage is, you may owe nothing additional, or more commonly you will owe a portion of your visit to the practice, even when you have active, in network coverage.

Why Am I Getting a Bill Now?

After your appointment, the provider sends a claim to your insurance company that includes all services performed. Your insurance then reviews the claim and applies your plan’s rules. This process can take just a few days, or in some cases 30-90 days or more.

This process determines:

• What portion of the visit they will cover
• What amount goes toward your deductible (if you have any)
• Whether coinsurance applies
• Whether any part of the visit is not covered by your plan

Receiving a bill does not necessarily mean that services were not covered or your plan denied any part of the visit. You can still owe money under one of the above categories for a fully covered visit.

Once the insurance company finalizes this, they notify both you and the provider. If any part of the cost is still your responsibility, a bill is issued for that remaining balance.

So while you may have paid nothing at your appointment, or you may have paid a copay, this often does not cover the full cost. That is why a bill may follow.

At My Visit, I was Told There Was No Charge

At your appointment, it's possible that there was no charge, which simply means that you do not have any copay (the portion that some plans require patients to pay at the time of service). While this may have been the case, it does not mean there is no charge to be seen by a provider.

After a visit is sent to your insurance plan for processing, depending on how your insurance plan is structured, you may be responsible for a portion of the visit. Once the visit is fully processed, your insurance plan sends us something called and ERA (similar to an EOB that you receive as the patient). This tells us how much, if anything, we must collect from the patient. 

The money we are required to bill our patients can be due to a copay, coinsurance, deductible, denied services, or a combination of these. 

Why Can't the Balance Be Discounted After Insurance Processes It?

This is another common question: "If I owe money after my insurance processes the claim, can't the provider just reduce or waive the balance?"

The answer is usually no, and here is why.

Healthcare providers sign contracts with insurance companies that legally require them to bill and collect the patient’s share exactly as determined by the insurance plan. These rules are put in place to keep billing fair and consistent for all patients.

If a provider reduces or waives your balance after insurance has processed the claim, it may be considered a violation of the contract with the insurer. In some cases, it could even be considered fraud. Exceptions are only allowed under formal financial hardship policies, which require documentation and approval.

What If I Still Have Questions?

If you're unsure about a bill or charge, here are the best steps to take:

• Review your Explanation of Benefits (EOB) from your insurance. This document outlines what was billed, what was covered, and what you are responsible for paying.
• Contact your insurance company to better understand how the charges were applied based on your plan.
• Reach out to the provider's billing department to get a clear breakdown of your visit and the balance due.

Medical billing can be confusing, but both the provider and your insurance company should be able to help clarify what happened and why.

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