Insurance: The Ins and Outs
Some of the most common questions we get here at Dixie Dermatology are about insurance plans. Health insurance can be extremely complex, but we’re here to help answer some of the most common questions.
What is health insurance?
Health insurance is a contract between you (the patient) and an insurance company. The insurance company agrees to pay your doctor for healthcare services they provide to you. You agree to pay your insurance company a monthly premium. In addition to monthly premiums, your insurance may also require you to pay a deductible, co-insurance, and/or co-pay, depending on your specific plan.
What is a deductible?
A deductible is a set amount that you must pay out of pocket every year before your insurance will cover your healthcare services. Deductible amounts can range from $0 to $8,000+. Some services, such as preventive care, may be covered by your insurance even before your deductible. However, every insurance has a different definition for what services they consider to be “preventive”. Deductible amounts reset every year in either January or July depending on your insurance carrier. For example, Medicare requires patients to pay a $283 deductible annually before they will pay for any medical care. This payment is a contractual agreement between you and your insurance plan: providers cannot edit, adjust, or write off any contractual payment amounts between you and your insurance.
What is co-insurance?
Co-insurance is a percentage of healthcare services that your insurance may require you to pay. For example, a common coinsurance is 80/20, where your insurance pays 80% of your medical bill while you are responsible for paying 20%. Your co-insurance amount can be paid by your secondary insurance if you have one. This payment is a contractual agreement between you and your insurance plan: providers cannot edit, adjust, or write off any contractual payment amounts between you and your insurance.
What is a co-pay?
A co-pay is a set amount that your insurance may require you to pay at every doctor’s appointment. This payment is a contractual agreement between you and your insurance plan: providers cannot edit, adjust, or write off any contractual payment amounts between you and your insurance.
Can I negotiate these prices with my doctor?
No. All deductibles, co-insurances, and co-pays are determined by your insurance plan. Your healthcare provider is legally obligated to charge you the amount determined by your insurance. Providers are only able to determine cash-pay prices for services rendered. These prices apply when a patient is not using insurance to pay for their visit.
How do I find out my plan details?
Some insurances list deductible amounts, coinsurances, and copays on your health insurance card. If these amounts are not listed on your card, call the phone number on the back of your card to speak with an insurance representative. They will be able to discuss your plan details with you.
Coverage for medically necessary vs elective treatments:
Insurance decides what treatments they will pay for based on criteria called medical necessity. Some criteria that would make a lesion “medically necessary” to treat include if it is painful, itchy, new, contagious, growing, spreading, etc. Insurance companies often cover medically necessary procedures. Insurance does NOT cover cosmetic/elective treatments, which could include things like Botox, cosmetic laser treatments, chemical peels, etc. However, every insurance plan has different coverage and some have certain exclusions for treatments they won’t pay for, even if they are medically necessary.
What does “coverage” really mean?
Just because insurance says that a certain service is “covered” does not necessarily mean that they will pay for it. If you owe a deductible, coinsurance, or copay, you will still be responsible for a portion of the bill even if the service is technically covered by your insurance.
What if I don’t have insurance?
That’s okay! We accept cash pay patients as well as insured patients. Our billing staff can discuss cash pay pricing with you before your appointment so that you’re prepared for any potential costs.
What if I have more questions?
Questions about your insurance are often best directed to your insurance. While your doctor may be able to provide information about what services you may need or general insurance information, they often are not privy to all of your plan details and may not be able to answer specific questions about coverage. The phone number listed on the back of your insurance card is your best resource for getting answers about your insurance plan.
