Holley Navarre Medical Clinic

Joel Rudman, M.D.



(850) 939-3999

My Blog


Insurance Q&A

Posted on November 7, 2015 at 1:30 PM
I'm comparing insurance plans. What are copays, deductibles, and cost shares?
Insurances typically try and encourage consumers to have some type of financial interest in their health, either in the form of high deductibles or regular copays. Copays are a regular amount due at every visit. Cost shares are usually a percentage of the doctor's bill the patient will owe. A deductible is the total amount a patient will pay before their insurance will begin paying medical claims.

When is a deductible "too high"?
It depends on the situation. If you never plan on seeing the doctor and just want peace of mind, you may be willing to pay less for insurance and accept a higher deductible.
Understand that this is not without risk. If you pay $5000 a year for insurance with a $10,000 deductible and you incur $9000 worth of medical costs, your total out of pocket medical expenses for the year will be $14000, and your "insurance" that you paid for will not even pick up a single bill yet.

I don't have a copay. Why did your staff charge me $77.77 ?
As stated earlier, today's insurance options range from ones with low deductibles and high copays to ones with no copay but astronomical deductibles. In today's high tech world, most offices can verify your insurance online and know ahead of time whether you have met your deductible. If your insurance tells us ahead of time you have not met your deductible, they will not be paying your bill for that visit. In that case, we do our best to estimate how much your visit will cost.

Has it always been this way? Healthcare is so expensive. I thought I remember not having a copay or a deductible.
Prior to the recent government regulation and involvement in the insurance industry, there were many different plans out there. Some plans offered by large corporations or small businesses had great benefits with little or no expense to the consumer. These so-called "Cadillac plans" were for the most part eliminated by Obamacare. So yes, you may have had a plan at one time with zero deductible and no copay, but those are unfortunately exceedingly rare in today's political climate.

I have insurance from my company, but I don't want to use that. I'll just use my Tricare insurance instead. Is that OK?
The way the laws are written, it is not up to the consumer which insurance they choose to use. The insurance companies themselves get to decide which insurance pays the bill. If you have two insurances, the one responsible for the bill is called your primary insurance. Generally speaking, government sponsored plans (Medicare, Tricare) are always secondary to a private insurance. The exception would be if you have a supplemental plan, which by definition is always secondary to Tricare or Medicare.

We just won't use my other insurance or I just won't report it to your office or to the claim. OK?
Absolutely not. Insurances devote entire departments, especially Tricare, to discovering whether or not you have other insurance that should be billed instead of them. Most insurances also have a statute of limitations to file a claim. There have been cases where Tricare has discovered other insurance was available and asked for their money back from us. If you fail to report all your insurances to our office, you will be personally responsible for the bill.

I'm having a hard time finding a doctor that takes my insurance. I don't understand it. It has low copays and covers a lot of benefits. Why don't doctors like it?
I can't speak for other offices, but the main reason our office  chooses not to accept certain insurances is due to burdensome paperwork. Some insurances, particularly Medicaid, HMOs, and Medicare HMOs, have significant bureaucratic requirements that small offices cannot meet. For example, some plans may want every lab or Xray pre-approved by some faceless bureaucrat. Other plans, particularly the Medicare HMOs, want a patient's entire chart mailed to them so they can have a record of everything single thing you reported or did. Aside from the massive amount of red tape this generates, I personally have a problem with sharing your sensitive and confidential information with every employee of Blue Cross or Humana. In my opinion, your insurance company in Jacksonville should NOT have access or proof to the time we discussed tobacco use, marital strife, or work-related stress. In a doctor's office, we are used to hearing extremely sensitive information that should not be mailed to insurance companies. I say no to plans that ask me to violate your privacy.

I received a bill, but I remember paying at the time of service. What's up with that ?
In some cases, a copay is collected up front and we are notified later by your insurance that you owe other cost shares. There may be a deductible applied to your claim. Sometimes an amount was collected based on the service we expected to provide (simple visit), but other charges were incurred (EKG, Strep test, tetanus shot).

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