Insurance is complicated, there is no doubt about it. If you haven’t had to use your health insurance, wonderful! I would like to hopefully make navigating your health insurance a bit easier with some general information.

COPAY: This is the patient’s responsibility for the office visit or any procedure that your insurance company has decided that a copay applies to. This varies from insurance to insurance. Some policies have copays for labs, radiology, ER, hospital stays.

DEDUCTIBLE: The amount you pay BEFORE insurance will pay.

COINSURANCE: The amount you will pay ONCE your deductible is met. For instance, on an 80/20 plan, insurance would pay 80% of the contracted rate and 20% of the contracted rate would be your responsibility.

CONTRACTED RATE: Your insurance has a contracted rate of reimbursement for doctors, out-patient facilities, urgent care, hospitals and other care sites. The medical service is billed out according to the CMS (Center for Medicare and Medicaid Services) pricing per the region. If the medical facility is contracted with your insurance, they must follow the insurance company guidelines of contracted rates AND what is considered an office visit or procedural.

OUT-OF-POCKET MAXIMUM: Traditionally, this includes deductible and coinsurance but not copays. If you meet your out-of-pocket maximum, usually you will not have a copay.

CPT: CPT stands for Current Procedural Terminology. These codes tell the insurance companies what was done. Some codes will be considered procedural/surgical even when done in an office setting. This is determined by the insurance company and by the company buying the insurance.

ICD-10: The ICD-10 stands for International Classification of Diseases, Tenth Revision. These codes tell the insurance company why you are being treated. In complicated cases the order in which they appear are very important, because they will support the procedure.

In conclusion insurance companies rule the world!

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