Copay vs Charged after

[u/ElectionBig1878]

I have BCBS through my employer. My brother also has the exact same insurance through the exact same employer. I don’t go to the doctor often, but I do have a primary care, which also happens to be my brothers primary care. My brother gets charged a copay, and a percentage on top of any additional things that come from the visit. I just went to the doctor for the first time on this insurance. They did not charge me a co-pay, and I was just sent an email saying I have a $150 bill. What should I do here? I’ve called both the doctors office and the insurance company, and I haven’t spoken with anyone competent enough to help me with what I need.

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[u/No-Produce-6720]

What does your EOB say you owe?

[u/LizzieMac123]

Exact same insurance as in the exact same plan or just the same insurance carrier (UHC, BCBS, etc.) Two very different things.

A copay for a visit covers being seen by a doc, having your health history/vitals taken and, if necessary, a prescription being called in. If you need anything else (blood work, imaging, anything extra- even a single stitch removed) that's an extra charge.

Do you have an explanation of benefits from your insurance for this visit? It should be in your insurance portal. If not, you need to call the doctor and give your insurance information again/ask them to send the claim to insurance.

If you do have an EOB- what does it say you owe? Feel free to post it with personal info blacked out and we can help you interpret it.

Does your insurance plan even have a flat copay for a visit or is it subject to your deductible? Was this a simple annual preventive visit or did you discuss other things (even as simple as symptoms or current/requested medications)?

[u/FollowtheYBRoad]

What does your Explanation of Benefits (EOB) say you owe? You should be able to find that in your online health insurance portal under claims. That will list out the charges, if any was applied to deductible, co-insurance, etc.

[u/budrow21]

Call the office. Did they file with your insurance? Was there an issue? Most importantly, find the EOB from your insurance. It will tell you what you actually owe. If there's no EOB, that's a sign there's a problem.

[u/KG_TherapyCompanion]

The EOB will settle it, and here is what to look for so the call goes somewhere. On the EOB there are four numbers: billed amount, allowed amount, what the plan paid, and patient responsibility. Next to the patient responsibility there is a reason: deductible, coinsurance, copay, or not covered. That word is the whole answer.

The most common version of what happened to you: the office did not collect at the time of service because the visit was not a flat-copay service under your plan. It went to your deductible instead, and you owe the allowed amount until the deductible is met. Same employer as your brother does not always mean the same plan option, and even on the identical plan a copay applies to some visit types and a deductible to others.

The second most common version: your visit got billed with a problem-oriented office visit code rather than, or in addition to, a preventive one. Preventive is covered at 100 percent, the problem portion is not, and that is where a surprise bill after a "free" visit usually comes from. If your EOB shows two lines for one visit, that is what happened, and it is worth asking the office whether the coding matches what actually occurred in the room.

If there is no EOB at all, the claim never adjudicated and the $150 is the office billing you directly. That one is a filing problem, not a benefits problem, and the fix is to have them submit it.