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What the hell is a deductible, co-insurance, and co-pay anyway?

Most of my patients are covered by some sort of insurance plan.  There are thousands of plans out there and they all have different rules and regulations.  I tell my patients all the time that their insurance plan is confusing ON PURPOSE.  When people are confused, they freeze and dont take action.  Your insurance company is hoping you will do this, not seek medical care, and not use your insurance.  That way, they keep your monthly premium payment and don’t have to pay for anything.  Good deal for them; bad deal for you.

I want to try to give you a brief education on the three key types of payments that patients make in my office and in medical offices of all kinds.  These payments are called “out of pocket costs” and are payments the patient makes on top of their monthly premiums.  Lets define them so you have a good understanding of what they are.
Deductible:  This is payment you will make for the year before your insurance company starts paying for your care.  Most people understand it better when we relate it to a car accident.  If you get in a car accident and you have a $1000 deductible, you pay the first $1000 of damage and your car insurance company picks up the rest of the repairs.  It is the same way in health care.  If you need medical care and you have a $1000 deductible for the year you pay the first $1000 in medical costs and your insurance company starts paying the rest for that year.  For your car, the deductible resets for each reported accident.  For your insurance, it resets every year.
Co-insurance:  This one can be a little tricky.  If you have a co-insurance, your insurance company will pay a percentage of your medical costs.  It could be 80%/20%, 90%/10% or any combination of percentages really.  Your insurance company pays the first number, you pay the second number.  Lets use round numbers for an example.  In an 80%/20% split if you went to physical therapy and the services cost $100, your insurance company will pay $80 and you will be responsible for paying the physical therapy company $20 for the visit.  If you got an MRI that cost $10,000 your insurance company would pay $8000 for the test and you will be responsible for paying the MRI center $2,000.  This gets tricky because most providers wont tell you how much their services cost.  In a future post I will tell you about my $18,000 MRI…
Co-Pay:  Finally!  An easy one!  A co-pay is a flat charge for a service.  No matter what happens at that visit, you are paying a set fee.  In my office these range from $10 to $85 depending on the insurance carrier.  It is a consistent fee that you will pay each time you receive service.
There are thousands of different plans out there and they are constantly changing.  They may be different depending on if you are visiting your doctor, your physical therapist, or your local imaging center.  That is why it is important that you understand your insurance benefits so you know what you are going to owe in out-of-pocket costs.  At Robbins Rehabilitation we verify and explain your specific benefits to you so there is no confusion.  Most medical practices just expect you to know them and send you a bill.  I have always thought this is unfair and that we should do more to help our patients.
Remember, insurance coverage is confusing ON PURPOSE.  Your insurance company wants you to get a big confusing bill so that you say “Well, I am not going to the doctor, physical therapist, anyone else anymore!   I had no idea I had to pay all this!”  Then the insurance company keeps your premium each month and never has to pay for anything.
You have to be an informed consumer.  Before you get medical service call the number on the back of your insurance card and ask them what your out of pocket cost will be for any medical care you need.  If you need physical therapy, let us know and we will call them for you and completely explain your benefits.  Sometimes it is easier to have someone working in healthcare help you navigate the tricky world of of insurance.

Todd Robbins


"We Help Individuals Live Pain-Free, Move Better, and End Their Frustration With The Right Diagnosis And Personalized Care"