Each time you see your doctor a claim is submitted to your insurance for the services you received. Your insurance will determine if your contract (your plan) covers the services. When the services are not covered, then the patient is responsible for the entire amount billed by the doctor.
When the services are covered, the insurance will reduce the billed amount (the total charges that the doctor’s office submits) to an allowed amount (the amount of the charges the insurance “allows” for the procedures that were performed). This allowed amount is then separated into insurance responsibility and patient responsibility. First is the patient’s responsibility: copayment and deductibles (if applicable) must be paid by the patient. After that insurance responsibility starts. Your insurance will cover a percentage of the remaining amount due (i.e. 80%) which they will pay to the doctor unless your contract says otherwise. The remaining (i.e. 20%) is the patient’s responsibility (this is the co-insurance).
Our office will call your insurance company before you come in to make sure you get the proper benefits and so we can tell you what your insurance will/won't cover.
Part of the "Understanding Insurance" series.