We constantly face issues with our health insurance. We pay our copay at each visit but then receive a bill for hundreds of dollars later. For example, I had 5 physical therapy sessions, provided my insurance info weeks before, and paid my copay each time.
Now, I’ve received a $200 bill. How is this fair?
Why do I get stuck with unexpected bills after paying what I was told I owed?
Am I liable for these additional charges?
Why can’t healthcare providers and insurance companies figure this out?
It seems like this provider location is an outpatient hospital, which can be more expensive. Some insurance plans apply these charges to your deductible and coinsurance instead of a copay. This billing method is still valid for both the provider and your insurance.
Why does your insurance indicate that you owe $600? Were any charges denied? If it’s due to your benefits, there might not be much you can do.
Yes, I agree. It seems OP went to an outpatient hospital rather than a clinic. This would explain why the clinic-based copay doesn’t apply and why there are two separate charges: one for the institutional claim (“clinic visit”) and one for professional services (the doctor’s fee). Additionally, the billed lab charges might be higher.
Here’s a question about this: On your EOB, does the office visit have a 992xx procedure code with a $70 copay? Are the lab charges, which start with an 8xxxx and include the 36415 venipuncture, subject to the deductible?
My guess is that you’re being charged the copay for the office visit and then the deductible for the lab tests. If you’re unclear about your benefits or how a claim was processed, it’s a good idea to call the member services number on your insurance card.
Claims are mostly processed automatically by AI, which isn’t perfect. I frequently see payment errors due to inaccuracies in the data.
The copay covers your office visit, which is essentially just the consultation with the doctor. It does not include any lab work or additional tests.
Check your EOB to see what you owe for the clinic visit. If it’s only $70, the billing was handled correctly, and you likely owe a deductible or coinsurance for the other services.
As a general rule, don’t expect to pay just a coinsurance for a specialist visit. There’s often additional specialty testing that isn’t covered by the specialist copay.
Also, while the doctor may be in-network, the lab might be an outside contractor and not covered. Always verify which lab the doctor uses and check with your insurance to ensure it’s in-network. You can request the lab order to go to a different lab if necessary.
I’ve experienced this myself; if the clinic is located within the hospital, they can legally charge you simply for being in the office waiting for the doctor. It’s frustrating!
I also agree with the previous points about lab charges versus copays for visits. You can always ask to see the billing codes for clarity.