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Do You Know. . .


What is the difference between copay and coinsurance? 

  • Coinsurance is a percentage of covered benefits that the patient is responsible for paying, such as 80/20. This means that the patient pays you 100% your contracted rate with the carrier for each visit until their deductible is satisfied. Once the deductible is met, the amount you collect is reduced to 20% of your contracted rate as the carrier pays the other 80% so you still receive your full contracted rate.


  • Copay is a flat amount that the patient pays a healthcare provider at every visit. The patient pays the same amount every time.

  • Source:  "Coinsurance vs Copay." Diffen LLC, n.d. Web. 21 Sep 2016. Read more. < >

How do I know how much to collect at each visit?
[ASSUMPTION: Let's assume that your contracted rate with ABC Insurance Company is $100 for a 90837 visit.]

  • We will create a banner above each patient's account that you can see in the scheduler and patient profile indicating what is to be collected. If the patient has a copay plan, you will see the dollar amount, such as $25. The patient will pay you $25 and ABC Insurance will send a check to you for the remaining $75.

  • If the patient has a coinsurance plan the percentage amount will be indicated, such as 80/20 after $1,000 deductible. The banner will indicate:  90837 = $100 until the deductible is met; then collect $20 - ABC Insurance will reimburse the remaining $80 to you via check and that is your complete contracted rate!

  • We'll do the math for you. As we receive the ERAs [think: electronic EOBs] the banner will be adjusted to reflect the correct amount to collect.

If I am contracted with Blue Cross Blue Shield am I in network for all their plans?

  • Not necessarily! Caution! ! !

  • Check with your area representative to make SURE you are contracted for ALL the plans you service. 

  • Example: A patient presents with a BCBS card and your front desk accepts it without verifying. The claim is denied because this plan  is Alliance and you are not contracted for this plan.

What is the difference between an EPO and PPO?

  • PPO plans generally cover out-of-network visits, although copays and coinsurance fees are usually higher for out-of-network benefits.

  • EPO plans do not cover out-of-network benefits at all. 

  • Source:  "EPO vs PPO." Diffen LLC, n.d. Web. 21 Sep 2016. Read more here. < >

What is the difference between HSA and HRA?

  • A Health Reimbursement Account, [HRA] and a Health Savings Account [HSA] differ in terms of eligibility requirements, who contributes into them, how the contributions work, who has ownership of the account, how portable funds are, and how the funds can be used.

  • The employer is the owner of the HRA account. This means that if an individual changes jobs or health plans, s/he will lose any money available in the HRA. 

  • The employee is the owner of the HSA account so s/he has access to the funds even if s/he changes jobs or health plans.

  • Read more. Source:  "HRA vs HSA." Diffen LLC, n.d. Web. 21 Sep 2016.< >

What is the difference between traditional Medicare and a Medicare Advantage plan?



  • The mental health benefit is 'carved out'. What does this mean?

  • Carveout: a service not covered in a health insurance contract. It is usually reimbursed according to a different arrangement or rate formula than those services specified under the contract umbrella. SourceMosby's Medical Dictionary, 9th edition. © 2009, Elsevier.

  • Example: A patient presents an Aetna card and you are in network with Aetna. No problem, right? The mental health benefits for this plan are carved to BHO [Beacon Health Options, formerly VO - Value Options]. Are you contracted with BHO??? Will the claims be set up to transmit to Aetna or BHO?

  • Example: A patient presents a Cigna card, however, mental health benefits are carved to Magellan. You are contracted with both carriers. No problem, right? Only if your billing department bills Magellan and not Cigna.




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