Paying for Physician Services When You Have Insurance Coverage

When you have HMO coverage, your physician visits are covered by your copay, which can range from $5 to $20. That is all you pay, assuming that you visit the PCP that is designated in your plan. Your copay will also cover the tests that the physician performs in his or her office, such as a blood test, urinalysis, EKG (heart exam), or X ray. If any of these tests have to be performed outside the physician’s office,you are still covered and will not incur any additional costs as long as your PCP is the one who authorized the test. If you have to see a specialist, you will also pay only a copay as long as your PCP referred you to the specialist and the specialist is in the plan network. If you visit a specialist without a referral from your PCP, even if that specialist is in the network, the insurance company will not cover it.
In an HMO plan, the physician has already agreed to the fee schedule and cannot charge the patient any more than the insurance will pay. In fact, the patient has no paperwork to deal with and except for the office visit copay, has nothing else to do in term of the charges. However,
the whole system falls apart if you have to see a physician outside the network. A lot of insurance companies will not cover out-of-network visits except for emergency situations.
If you have an indemnity plan, you can visit whichever physician you want but the company will pay only a percentage, usually 80 percent of what is deemed usual and customary. Physicians have all the control in terms of how much they can charge. The insurance company decides how much it wants to pay and the patient has to pay for the rest. There is a lot of paperwork to contend with and the patient usually ends up spending a lot of money out of pocket, whether he or she is seeing a PCP or a specialist. A patient concerned about the cost of a physician visit who has indemnity insurance should therefore inquire ahead of time how much the visit will cost. Work out a financial plan in advance by talking to the doctor and office staff to get a firm estimate of the treatment cost.
One way to reduce your physician fees even with insurance is to use the phone. Every time you visit a physician for care, you are charged a copay or your share of the indemnity insurance. Many times these visits are to seek comfort when dealing with a chronic illness or just to ask some questions. Some of these questions can be handled over the phone and your physician can determine if you actually need to come in. Do not abuse this privilege, however. If you get into the habit of constantly calling your physician for every little issue and then keeping him or her on the phone for long periods of time, the physician may start ignoring you or actually charge you for the phone consult.
The most important aspect in managing the cost of physician services is to understand what is covered and what is not covered, as specified in your insurance manual. Remember, your policy is a contract. If a service was not part of that contract, it is nearly impossible to get the company to pay for it. If you have any doubt about a service, call the company ahead of time to get clarification and if they say it is covered, get a written notice to that effect. This way if it has to go to arbitration or a court, you have a document to back you up.