Thursday, April 14, 2011

How a Medical Insurance Claim Works

Understanding how medical insurance claims work is essential to preventing any mistakes that could potentially interfere with future treatment. The general process of handling claims remains the same for all policies, but the specific provisions of the policy you have affects how involved you must be as the policyholder.


Virtually every health insurance policy requires members to pay a nominal fee when they visit their family physician or a specialist. Co-pays are fixed amounts that typically range from $10 to $50. Your co-pay is subtracted from the total cost of the office visit, and the remaining balance is invoiced to your health insurance company as an ordinary office visit claim.


Many policies have deductibles that must be fulfilled before the insurance company begins to contribute toward the cost of your treatment. Deductibles are fixed amounts that typically range from $1,000 to $5,000. Any claims submitted to your insurance carrier will be denied until you have paid an amount equal to or greater than the deductible.


Policies with co-insurance provisions require you to share in the cost of your treatment. Co-insurance amounts are fixed percentages that range from 10 percent to 50 percent. For any and all claims submitted, you might be responsible for as much as half of the total cost of those services.

Maximum Out-of-Pocket

Because the cost of medical services can be exorbitant, medical insurance policies contain stop-loss provisions that prevent medical bills from financially devastating consumers. This feature is called the maximum out-of-pocket provision, and is commonly between $1,000 and $10,000. Once you have spent an amount equal to or greater than the maximum out-of-pocket figure, any and all future claims are paid in full by your insurance carrier without the need for further contributions from you.medical insurance claims


New York Times: The Many Hidden Costs of High-Deductible Health Insurance
Money Under 30: Understanding Your Deductible, Co-pay, & Out-of-Pocket Maximum
Dough Roller: Weighing Health Insurance Costs

This article is a Twisted Nonsense Exclusive! (04/14/2011)

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