2 Answers

I believe co-pay is when you pay a set amount and the insurance company pays the rest. Co-insurance would be paid by one insurance company and the balance by another insurance company.

13 years ago. Rating: 0
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nope.

Copay is a charge you are responsible for - for every visit. So if you have a $20 copay for an office visit. You pay the doc's office $20 every time you go to the doc. (if you go twice in one day there is usually no charge for the 2nd visit.) but you owe this regardless of what your insurance pays.

so the doc billy the insurance

next thing is the insurance co looks at the claim and makes sure everything is covered. As an example - cosmetic surgery is almost never covered - they would deny this - whatever they do cover is the "allowed amount"

then the insurance company applies what ever discount they have negotiated with the doc. This is why it is important to use the docs the insurance company has contracted with.

what's left is the benefit amount - this is the amount the contracted doc will accept as full payment

finally the insurance company applies "co-insurance" - it splits the cost up into what they pay and what you pay. So with 80% co insurance - on a $1,000 benefit amount - they pay $800 and you pay $200.

What 6dog was refering to is called "coordination of benefits" - even more complicated...

13 years ago. Rating: 0
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