For anyone with health insurance, understanding what you can expect to pay for a visit can be a challenge. We’ll break it down for you here to help figure out how much your visit might cost.
Let’s start with some definitions. Three terms you should understand when it comes to your health insurance are co-pay, co-insurance, and deductible. When you use your insurance to pay for care, you will likely have to pay a co-pay or co-insurance for each doctor’s visit. A co-pay is a fixed amount that you pay prior to your appointment each time you see a doctor. Co-insurance is a percentage of the total cost of the doctor’s visit that your insurance requires you to pay. The amount of your co-pay or co-insurance will depend on your insurance. A deductible is the amount of money your insurance requires you to pay every year before they start to cover your healthcare costs. Some plans have high deductibles, which means you will have to pay a lot of money out of pocket before your insurance starts to cover your costs. Other plans have low deductibles, which means you will not have to pay as much out of pocket before your insurance starts to cover your costs. Your co-pay, co-insurance, and deductible are largely what determines what you will need to pay out of pocket for an office visit, if you use insurance.
Now that we’ve established some definitions, the next step is to understand how your insurance company treats visits to your primary care physician. Most insurance companies divide care you receive from a doctor into two types of care: preventative care, and problem-based visits. Doctors are required by the insurance company to “code” a visit as preventative, problem-based, or both depending on what is discussed during the visit. They then submit these “codes” to the insurance, which makes a payment to them later. Depending on the insurance, it can be anywhere from 30-90 days before this “claim” is paid back to the doctor. When that happens, you’ll receive in the mail an “explanation of benefits” from your insurance that tells you what services were submitted to the insurance company, what your insurance covered, and what portion you still owe of your bill.
Preventative care describes a very specific range of services designed to keep you healthy. Examples of preventative care include a screening colonoscopy for colon cancer, a mammogram or pap smear for screening for breast or colon cancer, or counselling from your doctor about stopping smoking. For most patients, preventative care services are addressed once a year in an “annual preventative visit”. However, it’s not always so simple: sometimes, tests that are normally considered “preventative” are actually classified as “problem-based” by your insurance company. For instance, if your have a mammogram because you found a breast lump, your insurance may consider the test “problem-based” care rather than preventative care, since it was ordered to diagnose a specific problem, rather than to prevent a problem. Similarly, even though screening for high cholesterol is covered as a preventative service, if you already have high cholesterol, checking your cholesterol every year may not be. Each insurance handles these issues slightly differently, so be sure to check with your insurance if you’re unsure what counts as a “covered” preventative service.
Problem-based visits, sometimes called “sick” visits, are visits to the doctor to discuss a new concern, or to follow up on a previous condition. These visits can be short, like seeing a doctor for the flu, or longer, like seeing the doctor to follow up on your blood sugars when you have diabetes. The total cost of these visits depends on a number of factors, including how many issues were addressed, how long the visit was, whether your doctor spent additional time outside of the office visit coordinating with other doctors or reviewing records to address the issue, and how complex the issue is to manage. Generally speaking, the more complex the problem and the longer it takes to address it, the more expensive a problem-based visit will be.
To make matters more complicated, there are plenty of visits where both preventative services and problem-based care are discussed. Depending on your insurance, you may receive a bill for problem-based care that was discussed in addition to recommended preventative services, or for a lab that was considered to be “problem-based” rather than preventative. Scheduling a separate appointment to discuss new or existing problems in detail is the best way to avoid your insurance company classifying a visit as problem-based rather than preventative.
For patients without health insurance, what you pay for a visit is far more simple to determine – simply call your doctor’s office and ask what their rates are for self-pay individuals. Scheduling a visit with your primary care doctor is often the least expensive option, while visits with a specialist, to an urgent care center, or to an emergency department or hospital tend to be more expensive. Similarly, going to an independent lab or imaging center rather than a hospital-based one is likely to save you money as well – but we’ll talk about that more in a separate post.
Understanding what you’ll pay for an office visit can be a frustrating process, especially since insurance coverage can change every year. If ever in doubt, check with your insurance company to confirm that the doctor or service you’re trying to access is covered under your plan. Keep in mind that, even if your plan “covers” a service, you still may need to pay a co-pay, co-insurance, or deductible out of pocket before your insurance kicks in. In a future post, we’ll talk about ways to save money on healthcare – whether you have insurance or not!