I have health insurance with a $500 deductible. If I go to the doctor and the bill is for example $400, I am required to pay the $400 and a $10 copay by the insurance company. Can insurance companies legally require that I have to pay a copay when I am paying 100% of the doctor's bill?

  • In situations like this, typically the copay would be separate from the $400; the $10 would be for the visit, and the $400 would be for tests done or something to that effect, not the visit itself. Either way, definitely read your EOB separately from the doctor's bill and make sure they agree, and if not talk to your doctor's billing office and/or the insurance (sometimes both on one conference). – Joe Dec 2 '14 at 23:02

In cases where there is a deductible and a copay the following has occurred: The doctors office has collected the insurance company mandated co-pay. Then after the doctors office has submitted the paperwork to the insurance company, the amount that I owe is calculated.

Because of agreements between the insurance company and the doctor the maximum amount the Doctor can charged is generally lower than the the $400 billed, lets say $300. Because I already paid the $10, the explanation of Benefits (EOB) would then specify that I would owe an additional $290 to the doctors office. I would then get a bill from the Doctors office for the $290. I would be credited with $300 towards my deductible and $300 towards the maximum out of pocket.

I have never been billed for the negotiated amount plus the co-pay.

The next time the amount would be split between meeting the deductible, and having met the deductible categories. The doctors office doesn't want to be involved in determining if the deductible has been met, because it can change in an instant if the family is large.

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