Wiki Copayment towards office service charge?

[kpeterson15]

I have a very basic question, yet still confused after a class I just took. Does the copayment you pay go towards the payment of services such as an office visit? For example, I have an office visit. At the time of the visit, I have to pay $20 copayment. Two weeks later, I have a charge for the office visit for 120, does my copayment go towards that? So, my total I would need to pay would be only 100, or is it still 120 and the copayment is a totally separate charge? I have two professors saying something different. Also, this is scenario is for commercial insurance.

 

[SharonCollachi]

I don't know what you mean by "two weeks later", so I'll just do the best I can.

Your copay is not a separate charge.

You have a visit at the doctor's office. They charge you a copay of $20. They bill your insurance $200. Your insurance prices your claim at $120, writing off $80 due to insurance contractual adjustment (your doctor's office has agreed to accept $120 total for the office visit).

Scenario 1: Your insurance pays your doctor $100. There is no balance due ($200-$80-$20-$100).

Scenario 2: Your insurances pays your doctor zero, and puts $100 to deductible and $20 to copay. You pay the $100 deductible when the doctor bills you, because you already paid the $20 copay.

Scenario 3: Your insurances pays your doctor $120, because you've already met your max out of pocket for the year, and the doctor refunds you $20.

 

[kpeterson15]

I don't know what you mean by "two weeks later", so I'll just do the best I can.

Your copay is not a separate charge.

You have a visit at the doctor's office. They charge you a copay of $20. They bill your insurance $200. Your insurance prices your claim at $120, writing off $80 due to insurance contractual adjustment (your doctor's office has agreed to accept $120 total for the office visit).

Scenario 1: Your insurance pays your doctor $100. There is no balance due ($200-$80-$20-$100).

Scenario 2: Your insurances pays your doctor zero, and puts $100 to deductible and $20 to copay. You pay the $100 deductible when the doctor bills you, because you already paid the $20 copay.

Scenario 3: Your insurances pays your doctor $120, because you've already met your max out of pocket for the year, and the doctor refunds you $20.

2 weeks later was just an example of getting a bill for the office visit later. But thank you for your answer!

 

[SharonCollachi]

Okay, that's what I thought. There are some really complicated plans out there. One of our local school districts has a plan that has a copay of $25 plus 20% of the remainder. In your case, that would look like this:

Contractual rate: $120
Copay $25
20% Copay = $120-25 equals $95. Then take 20% of $95 equals $19 <--- additional copay

So the copay = $25 plus $19 equals $44, and the insurance pays $76 ($120-44).

That's what $25 plus 20% looks like!