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What does my insurance pay?

It's a racket, and we all know it. Unfortunately, this is the system in which we live, so we will try to explain how it works so you will have a more thorough understanding.


First of all, insurance usually does NOT fully pay for much outside of a routine exam and normal health maintenance screening like a pap, mammogram, or STI testing. Other than that, check a few key terms (thanks to healthcare.gov for this) to more fully understand this convoluted system:


Benefits: This is what is "covered" by your health plan. This usually includes routine annual care and a discount on some prescriptions. Depending on your plan, you may also have imaging, mental health, or emergency room visits included. Make sure to check!


Deductible: The amount you owe for covered health care services before your health insurance or plan begins to pay for sick care. After that, you still may owe coinsurance.


Coinsurance: Your share of the cost for a covered health care service, usually calculated as a percentage (like 20%) of the allowed amount for the service.


Copay: An amount you pay as your share of the cost for a medical service or item, like a doctor's visit.


Premium: The amount you pay for your health insurance or plan each month.


Network: The doctors, hospitals, and suppliers your health insurer has contracted with to deliver health care services to their members. If you go out of your insurance network, you could be responsible for massive fees and costs which your insurance will not pay.





For example, you have a large ovarian cyst which is causing you pain and you need a surgery. While we will ensure that the surgery is "approved" or "covered" from your insurer, coverage does not mean that the entire cost is paid for by your insurer. Remember, your insurance company wants to do one thing: keep your premium and pay out less to you than they take in.


One key thing to do: READ your plan. See what your deductible is. You may have to pay anywhere from $200-$10,000 before your insurance will even pay a portion of your surgery. Even if you have met your deductible, you still may owe a percentage both to the hospital (this is always more, BTW) and the surgeon, anesthesiologist, etc from your coinsurance.


Another example: You are in the office and have recurrent vaginal discharge which has not been helped with routine treatment. Your practitioner orders an expanded bacterial panel to find out what else may be going on. This lab cost (from which the office does not profit) will likely apply to your deductible, and may be hundreds of dollars. You are entitled to ask the lab about these costs.


Here's a big one: You need to come in for routine gynecologists' care. At the time if your visit, you need to discuss your irregular periods, pelvic pain, or other issue. While a routine exam may incur no cost, if we discuss issues outside of wellness, this counts as a sick visit, and you may owe a copay or even deductible.


Billing: When you see your bill, you may see a large amount billed. While it appears that we recoup all that we bill, this is never the case. We will usually get around 50% of what our bill may be, because as a small business, we cannot negotiate better rates with these large companies. Therefore, we depend on you, our patient, to provide your copay, deductible, or coinsurance to survive.


Does this make sense? The key point here is to KNOW YOUR INSURANCE. Don't just sign up for the first plan on your employers list. While a less expensive plan may be right for you, read everything and know what is covered, and more importantly, what is NOT.


We'll be back to discuss the different types of insurance: HMO, PPO, EPO, and POS.


Thanks and hope this helps!


Dr. Williams






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Nadia Hasan
Nadia Hasan
Apr 12, 2023

This is all great, but you should do everything possible as an establishment to avoid surprise charges. I'll give you an example: I go to a Dentist office who, before scheduling me for my next visit, will take the time to run the procedure code through the insurance to let me know how much it causes. That way, with their help, along with me understanding my healthy insurance policies, we can together help me make an informed decision about my care. You don't even need to do that, at the minimum let your patients know the procedure code and they can do it themselves.


There is too much passing the buck here by calling it "a racket". You as an…

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