Professional Opinion: How can I avoid unexpected costs at the doctor's office?

rdamgen@beaufortgazette.comMay 5, 2014 

Gloria Byron is a market operations manager for Tenet Physician Resources.

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This week, Gloria Byron, a market operations manager with Tenet Physician Resources, discusses how to avoid or be prepared for large bills for procedures and tests that come after a doctor's visit.

Question. Sometimes I go in for a doctor's visit, pay my $20 or so co-pay, and end up with a large bill for procedures or tests I would have opted out of had I known. How can I avoid extra costs at the doctor's office? If I have an insurance billing questions, where should I start? With my doctor's office or with my insurance company?

Answer. With so many changes evolving in health care and different insurance plans, it is very difficult for physicians to know exactly what is and is not covered by each patient's plans. The physician is ordering and providing services based on what he or she has deemed medically necessary for your treatment.

The most important way to avoid unexpected costs from your doctor visit is to make sure that you understand your insurance policy. You can start with calling your insurance company and having someone explain your benefits to you and how they are applied to your services. Based on your policy, you may have only a co-payment or you may be required to pay the full allowable amount until your deductible is met.

A co-payment or co-pay is a fee that you pay for doctor's visits. Co-payments may vary based on a doctor being in or out of network as well as on the doctor's specialty.

The deductible is the amount of money that you are responsible for paying in a calendar year. After your deductible is met, you may not pay anything or you may share the remaining cost up to an out-of-pocket maximum. In addition, you may have a coinsurance percentage that is applied to each service. Coinsurance is a health care cost shared between you and your insurance company. The cost sharing ranges from you paying 20 to 100 percent of the medical expenses until you have reached your out-of- pocket maximum.

Procedures, laboratory tests and radiology exams are generally not covered under your co-pay. Based on your policy, these services may be applied to your deductible or coinsurance. It is also important to make sure that you are seeing a provider that is in network with your insurance.

When you are seeing your doctor, make sure that you ask questions regarding what is being ordered. If a procedure or other services are being ordered, you can contact your insurance to verify what the out-of-pocket expenses would be prior to having them done. You will need the procedure codes, which someone in the physician's office will be able to give you, or they may be on the order. There should always be someone available in the physician's office that can also answer your billing questions.

Insurance and medical billing can be very confusing. If you understand your insurance coverage and stay informed regarding your medical care, you should be able to avoid those unexpected extra costs.

Follow reporter Rachel Damgen at twitter.com/IPBG_Rachel.

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