CO-PAY!!!

caliotter3 · Mar 27, 2018

My copay for ER visits used to be $50 per occurrence, but that was with my insurance. You need to check with your insurance and you are right, this should have been discussed upon admission.

sallyrnrrt, ADN, RN · Mar 27, 2018

My co pay is between $100-200, depending on which ins. I currently have

Being admitted for observation, is not the same as being admitted in patient....

JustBeachyNurse, LPN · Mar 30, 2018

Observation is an outpatient benefit. You need to review your coverage. Copay is a fixed amount unless you have a deductible. My ED copay is $150 unless admitted inpatient. 23hr observation first goes to my $750 deductible then 20% coinsurance until max out of pocket of $1500/yr. you need to know your benefits.

this has zero to do with any health care rule or law but everything to do with the insurance plan you have.

Neats, BSN · Mar 30, 2018

Each plan is different but there are many similarities in most plans. People need to be educated on their medical benefits and with the new trend for narrow networks here is some education. Narrow networks are the new trend (they have been around for a long time) and really decrease your choices to who you can see, as long as the provider is on the narrow network list you are in network. If there is no provider on the list you need work close with your insurance company and provider to obtain a specialty provider that is approved for in network rates. Do not leave this up to your provider to do this... Know what benefits you have.

Most plans designate a percentage of covered charges until out of pocket are reached which then a plan usually kicks in at 100 percent. Some plans are high deductible. An example is a family plan has a $10,000 deductible and an individual out of pocket at $5,000. Say you stayed in ED observation and the bills came to $4,500.00 you still have to pay a deductible until the last $500.00 is reached, once this is reached, your bills for the remainder of your plan year has been met for deductible for individual... so you will not have any more out of pocket and the plan will pay for you at 100 percent, even though you have not met the family deductible.

These bills are not just the emergency bills, they include imaging, lab, consultation with specialties and there are exclusions...most plans do not add the following to the deductible:

1. premiums

2. pre-certification penalties (services rendered that have not been prior authorized, they will pay at a discounted rate as much as 50 percent)

3. charges over the non-network allowable amount (non in network providers usually pay at 50 percent and you the patient will be responsible for the other 50 percent)

4. charges for services not covered under the Plan (considered investigational or not medically necessary, you the patient are responsible for all charges)

5. balanced billed charges (provider can bill you for any charges not paid by insurance by what NOT is in your insurance contract)

There are a lot of factors that go into your insurance coverage and we are being nickeled and dimed (in the thousands)...knowing what is covered in network and out of network is helpful to you and saving monies. I suggest a in network verses out of network sheet you keep in your files for the year. Hhere are some more helpful tips:

1. Know what is needed for prior authorizations (also known as pre-certs) be aware that just because your doctor office says there is no prior auth needed they maybe mistaken. It is in your best interest to call your insurance for a benefit quote and obtain/confirm the name of the provider you want to see is in network. Get a encounter number from the insurance (not provider office) for the call. You can then provide this information to your provider.

2. Review all your Explanation of Benefits (EOB's). I had one where my provider billed to the urgent visit which I only have 5 annually, I informed my insurance company that this was a regular schedule visit, not urgent visit and that I want it corrected...what if I needed those urgent visits? I would be paying more money after the 5th one for sure.

Knowing these things should save you and your provider so many headaches.

Keep that HR copy of medical benefits handy, highlight what you think you need, related to your diagnosis, possible injury,...

I know this is long but I want my peers to know in the end your medical benefits are your responsible to know, the provider office only process insurance as a courtesy they are not really legally mandated to do so, and those that are working in the office billing department change frequently some come with experience some have limited experience so it is a hit or miss for applying your benefits to their services. You the patient need to take charge and ensure you get the maximum out of those benefits.

Contacting your insurance company for guidance is a good avenue to take, Insurance companies only manage your benefits your company wants you to have we are not big and bad.... Ask those questions and get the confirmation number for that call. You will be so much more educated about your benefits and your provider is more than willing to use those benefits in your favor if you do your he homework.

MunoRN, RN · Mar 30, 2018

Copays are nothing new, and along with the deductible are the main things you look at when choosing a plan; you can choose to pay lower copays and lower deductibles by paying higher premiums, or vice-versa. Typically ER copays are a few hundred at the most, your deductible on the other hand might be much more than that.

Been there,done that, ASN, RN · Mar 30, 2018

Payment is not addressed at the time of the incident. The facility needs to treat you and duke it out with the insurer, after. The facility that has a clerical worker chase you down .. does NOT know the program. That is entirely inappropriate, check with your insurer.

In my case, I would rather have an observation..that is covered 100%. Again, it depends on your coverage.

Best wishes, hope you are well.