Paid Dr. Copay and STILL got billed.?

Question

Ok, I am sick of this blue cross insurance I have. I went to the doctor and talked to him for maybe 5 minutes. He did not do anything, did not prescribe me anything. I talked to him about the medicine I was taking, that is it. I paid my copay. I thought I had an understanding that when you go see a doc. you pay the copay and that is it. I thought that is what the copay is for...right? I get a bill from blue cross that I owe more money from that dr appt...that the amt is more than the insurance co. will pay.

What the heck is this? What the heck is a copay for then??? I went to see the doctor a few months ago when I got my yearly exam, paid the copay and then got a bill saying I owed another 70 bucks! Does anyone work in insurance or know if this is right or not? What the heck is a copay and insurance for if I'm paying so much per month and pay a copay and I STILL owe money....

yes, the doctor is in my network, I am positive of that, it said it on my statement.

What is the copay for, I was always told that when you have a copay it is for the dr's appt, and what you have done there is covered under that copayment.

If I have to pay that extra money, it would end up costing me $48 to literally talk to the doctor five minutes!!! That is rediculous!

I have individual insurance, my employer does not provide it, so I already pay a lot per month to have it.

Anyway, I used to have individual GHP insurance and NEVER had this problem. And ever since I got blue cross blue shield, every doctor visit I have always comes with a $20 or more bill after the copayment. I do not understand that. Doctor visits and medical care cost is getting out of hand. I pay 90 out of pocket each month for insurance, plus get a $50or so bill after my $25 copayment every doctor visit....it's so expensive to even go to the doctor these days.

Answer 1

Okay, well first of all, you didn't get a BILL from Blue Cross. You got an explanation of benefits (EOB) showing how they processed the claim. Blue Cross doesn't bill you - your doctor does.

Your co-pay applies when you visit the doctor in his office. You're right, you should pay the co-pay and then the insurance will pay the rest. UNLESS... you're seeing an non-network doctor. DOUBLE CHECK to make sure your doctor is indeed in the network.

Also, CALL BLUE CROSS! No one here can accurately answer your question because (1) we don't know enough about your medical plan and (2) we don't know if the doctor is in-network, non-network, a specialist, or any other variety of reasons why the claim might be considered differently. Only BC can tell you that. Call the number on the back of your card and ask for a supervisor. Don't take NO for an answer. Ask them to explain why you're being asked to pay more than your co-payment.

Answer 2

ok, with insurance it could be one of two things .

First is deductable . That is the amount you pay before the insurance will pay anything. It can be 0 in some plans .

Then there is co-pay. Its like you pay 5% and the insurance pays 95% of the bill. Or it might be fixed where you pay $5 or something.

The insurance company may have limits though where they say a visit of less than 10 minutes is worth $70 and that is the most they will pay. If your doctor charges $90 for that visit you pay $5 copay, the doctor bills insurance for $85 and they actually pay $70. The doctor then bills you for $15 that wasnt paid.

Most plans have a list of doctors who will charge the insurance companies rates..

Ask your doctors office to explain it to you.

Answer 3

I've been seeing this a lot with my participants-the providers are billing THEM for the negotiated discount amount. I have to go digging to find out that the participant is being billed for the discount, and send a new copy of the eob to the provider and then, sometimes, they come back and say they're not contracted with the network.

If you have a benefits person at your company, I would ask them for some assistance. There may be something in your plan that you're not aware of, or it could be that BCBS is just screwing you blue like they are thousands of others across the country! The more I hear about that company, the happier I am that we didn't go with them. They tout this high (over 90%) auto-adjudication rate (that means that no human hands touch your claim), but it sounds like the machine is more fallible than man. Get those claims checked out before you pay anything more.

Answer 4

Why would Blue Cross bill you? Sounds to me like you got an EOB (explanation of benefits) from Blue Cross showing what they will cover. They send this to the doctor and the doctor will write of the amount over the contractual allowance. I can not answer for sure as I have not seen paperwork but that is what it sounds like to me.

It is also possible BCBS denied claim and that is why you are being billed. This is often the cause because doctors office will miscode and the insurance company will deny. You need to wait until you get the actual bill from the doc. Call and ask BCBS why they did not pay and then if needed call doctor and have the resubmit claim correctly.

Answer 5

Well, unless you're the President or someone else at a company that pays 100% of the medical bills, then you're just like the rest of us.

Your co-pay is exactly that. Your co-pay is what you normally pay the doctors. It can be a percentage or a set amount like $10, $20 or $35 each visit.

Then, if your insurance company has an agreement with that doctor, the doctor can just accept the insurance payment and your co-pay as payment in full. If you doctor does not have that agreement with the insurance company, they can and will bill you for the balance.

Too many people assume that just because they have insurance, they don't have to pay anything other than the co-pay. Wrong! Insurance is exactly what it says it is. Insurance against the probability of you getting sick or needing treatment. Insurance is there to HELP pay the bill, not pay for the entire thing for you.

And the part about "just talking to the doctor"? What part of the doctor's time don't you think they should be paid for? The doctor's time is just as valuable as yours. Some people even now have to pay for a telephone consultation.

I would suggest that you actually read the insurance information or better yet, contact the insurance company and talk to them about finding doctors they have a contract with - also known as "In Network".

Good Luck!

Answer 6

The additional amount is called "direct" or "out of pocket" payment. You have a copay for each visit and a maximum annual out of pocket payments each year which usually is about 2000 dollars total per family and after that you are covered 100% after your copays at the time of each visit..

Millions of french workers are asking a very similar question. They pay about 20% of their paychecks for mandatory government heathcare insurance only to face copays, deductibles, and huge direct payments. About 80% of french workers carry additional insurance just to cover these additional payments.

Additional comment:
Each year the cost of heathcare insurance rises for employers. In many cases the employer is paying an amount equal to what the employee has deducted for insurance payment. As a cost-cutting measure, many companies have to choose insurance plans that offer less benefits. Ask your employer if supplemental insurance like AFLAC can be made available. It is very inexpensive and does help cover these additional expenses.

Answer 7

It sounds to me like you have a cost-sharing plan, which is becoming more and more common these days because the premiums are much cheaper.

Call member services (the number is on your card) to confirm.

With a cost-sharing plan, you pay your copay, AND then a portion of the visit or procedures, depending on your cost-sharing rules.

If you do, in fact, have a cost-sharing plan - this is legal and correct.

(PS- if you're paying $90 a month in premiums, don't complain. I pay $500 for just me. )

Answer 8

Are you going to a doctor in your network? Usually with BC if you go to a doctor in network they pay 100% after co-pay...if you go to an out of network provider they pay 80% after co-pay and you are responsible for the other 20%. You should check with your employer though, they will have a list of your benefits and who is in-network and who is out of network.

Answer 9

take the insurance statement to the Dr --to check -- if their claim forms are not coded correctly they get denied and the drs have to resubmit a corrected claim--this has happened to my sister several times

or --usually with co-pays that is your deductible -- unless out of networked -- did you have to meet a certain out of pocket deductible before the co-pays kick in?