Almost everyone is now familiar with copays. These are the flat fee charges that insurance companies require that patients pay each time they have a visit a doctor. When copays were first instituted, they applied only when a patient actually saw a doctor. Now these fees encompass of variety of services. Here are some points to keep in mind when trying to determine if you are responsible to pay a copay.
If your insurance plan requires copays, you will be responsible to pay a copay each and every time you have an office visit. This visit could be with the doctor, or if could be with a nurse, nurse practitioner, or physician’s assistant. If your provider is billing an office visit procedure code, you will be responsible to pay your copay. If your visit to the office is simply for a blood draw or an immunization, an office visit procedure code should not be billed and therefore, you may not be responsible for a copay.
One exception to the “copay for each visit” rule is yearly well visits/physicals. Most insurance policies do not apply a copay to this one yearly visit (note: for women, your policy might entitle you to a copay-free well-woman visit in addition to a yearly check-up with an internist). Refer to your policy, your insurance card, or speak with a customer service representative to confirm if copays are applied to yearly well visits under your plan.
It is becoming increasingly more common to see copays that scale in cost by the place of service. Depending on whether you see your primary care physician or a specialist, the copays could vary, often significantly. Additionally, some policies require that you select a primary care physician and list that person on your records. If you fail to do this, every visit to every doctor, whether the doctor is your internist or a specialist, will be charged at the higher specialist copay rate. If this is a stipulation of your plan, be sure to register your PCP with your insurer to avoid the higher copays.
Emergency Room and Urgent Care Visits
Almost all policies require a copay for a visit to an ER or Urgent Care Center. In most instances, the copay for an ER visit will be substantially higher than that for the Urgent Care Center. It’s a good idea to locate Urgent Care Centers in your network that are close to both your home and office. Knowing this in advance will enable you to access urgent care more quickly and at lower cost.
This is the one area that has been experiencing rapid growth. More and more, insurers are applying copays to tests that are conducted not only in doctors’ offices but also in labs and other facilities. There is no way to easily know if your plan applies such copays to tests without calling your insurer and asking the customer service representative. When investigating copays in this area, you need to be sure to be very specific with your questions. It is advisable to obtain the procedure codes and the diagnosis codes that your provider will bill for these tests in advance of receiving them. Share those codes with your insurer and have the customer service representative confirm which tests will have copays and what the copay will be for each test.
All of this advance legwork will help you avoid medical bill problems that could culminate in expensive medical debt. If this process seems too confusing, enlist the help of a medical claims advocate. These patient advocates will know the questions to ask your insurer in order to confirm your financial responsibility for medical services.