Sapoznik Insurance, A World Company

Understanding insurance fees and access

Without fail, I always receive questions and concerns about plan deductibles. Most believe that you must satisfy the entire deductible before any services are covered. Let’s put that myth to bed. The annual deductible applies only to the services billed until the deductible is met. The member is only paying the contracted price for that service, which will reduce the deductible by that amount. For example, if you have a $2,500 deductible and a scheduled MRI that costs $500, you will only be responsible for the $500. The $500 is then applied to your deductible, reducing your remaining deductible responsibility to $2,000. The most a provider can require you to pay is the contracted amount for the service until the deductible is met. Something to keep in mind is that sometimes if you contact the provider directly, in this case, an imaging center, and you don’t go through insurance, it can cost you far less.   

To avoid unnecessary or exorbitant costs, the first thing is knowing where to go for care. Most places, including emergency rooms, urgent care centers, doctors’ offices, etc., have contracted prices with the insurance companies. And they differ. The most expensive place to go for care is usually the hospital, and unfortunately, it is the first line of defense for many people. Services rendered at a hospital or emergency room will be the costliest since they negotiate much higher contracts with the carriers.  

Hospitals are for emergencies and life-threatening situations including:  
  • Severe chest pain or difficulty breathing 
  • Weakness/numbness on one side 
  • Slurred speech 
  • Fainting/change in mental state 
  • Serious burns 
  • Head or eye injury 
  • Concussion/confusion 
  • Broken bones and dislocated joints 
  • Fever with a rash 
  • Seizures 
  • Severe cuts that may require stitches 
  • Facial lacerations 
  • Severe cold or flu symptoms 
  • Vaginal bleeding with pregnancy 

Otherwise, a good rule of thumb is that if your sudden illness or injury is something you would typically feel comfortable addressing with your primary care physician (PCP), then an urgent care center or walk-in clinic setting is more appropriate.  

Telemedicine:  

Telemedicine offers access and convenience. Once the pandemic hit, people understood the value of telemedicine, and its popularity went through the roof. Telehealth visits, which made up about 1% of medical visits before the pandemic, jumped to roughly 50% in 2020. However, it has created confusion about fees and access. It is important to note that medical plans often cover telemedicine, and the member usually pays according to their plan PCP co-payment schedule. There are even new programs that if you call the doctor for a question, there are no out-of-pocket fees.  

The pandemic has changed the delivery of health care and is likely to affect how health care services are offered, priced, and utilized. 

Reach out today for more on the latest health care trends and resources.  

By Ileana Miranda, Employee Benefits Consultant, Sapoznik Insurance, A World Company