When a healthcare provider agrees to participate in a specific insurance plan, they agree to accept as payment in full the amount the insurance designated as the allowable reimbursement amount for a given service. The difference between the actual charge and the insurance company’s allowable is considered a contractual amount that must be written off. Some insurance plans pay only a portion of the allowable. The payment amounts from your insurance company will depend on what co-payments, co-insurance, or deductible you may be required to pay.
Your insurance plan may have set amounts you are responsible to pay for specific services. Co-payments are most commonly associated with office visits, hospital emergency room or urgent care visits, and prescription drugs. Although not as common, some plans do set co-payments for radiology services.
Your insurance plan may only pay a portion of the allowable reimbursement. The remaining co-insurance amount is your responsibility to pay. The amount will depend on your insurance benefit. For example, if the allowable for a service is $100.00, and your insurance pays 70% ($70.00), your co-insurance would be $30.00.
Your insurance plan may require you to pay for a specific dollar amount of health care services per year before they begin to pay your medical bills. This amount, the deductible, will depend on your insurance company and your specific benefit plan. For example, if the allowable for a service is $100.00, your deductible is $100, and you have not yet paid any medical bills this plan year, you would be responsible for the entire $100.00.