Understanding Your Insurance Benefits

Your health insurance benefits can seem confusing and sometimes overwhelming.  At Cole Pain Therapy Group, our Insurance & Billing staff deal with insurance companies on a daily basis, and they are dedicated to staying abreast of policies and procedures concerning health insurance plans.  We’ve seen many changes over the years and we can certainly understand the frustration and confusion associated with today’s ever-changing health insurance environment.

Simply understanding the terminology is a step in the right direction. For example, deductible can refer to an individual or family amount.  Deductible refers to a particular dollar amount that is paid by a patient before insurance will start covering the cost of medical care.  After the deductible is paid, the patient will also be responsible for a co-insurance amount, commonly 20%.  The co-insurance would come in to play once the deductible has been fully satisfied.  For example, if your deductible was $1500 with a 20% co-insurance, you would be responsible for $1500 before insurance would actually start to cover the care.  Once that $1500 deductible has been satisfied, insurance would consider paying future claims at 80% of the allowed amount, leaving you responsible for the remaining 20%.  FYI- You should never be asked to pay the full deductible amount to your provider’s office during one date of service, unless that date of service involves procedures that costs up to the $1500 deductible.  For example, if your visit today to your provider’s office totals $250 in allowed fees, you should not be asked to pay the full $1500 that same day, only the $250.

The allowed amount refers to the dollar amount that your insurance will consider for services rendered.  For example, your doctor may charge $50 for a particular service, but if he or she is in network with (contracted with) your insurance company, the insurance will have a set price for that particular service, such as $21.  The allowed amount of $21 would be the amount considered for payment by your insurance, based upon your particular benefit structure.  If your deductible has not been satisfied, you would be responsible for the $21.  If the deductible has been satisfied, you would typically pay the co-insurance amount, such as 20% of the $21, and insurance should pay 80% of the $21.  (Of course, these dollar amounts are for example purposes only.)

On the other hand, your benefit structure may include a co-pay.  This is a flat amount, such as $35.00 or $50,  for each doctor visit. This makes it easy because there is no deductible or co-insurance.

Some insurance plans have a copay for one type of medical procedure and a deductible for others.  For example, there may be a co-pay for examination/diagnostic procedures and a deductible for treatment procedures.

Our doctors customize each treatment plan to meet your specific, individual needs.  This is why our excellent Insurance & Billing staff is available to answer your questions and assist by filing your claim for insurance coverage.  For those with limited to no insurance coverage, we maintain excellent rates for all of our chiropractic services.

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