Understanding Insurance Terms: Co-Pays, Deductibles and Facility Fees - Premier Pediatric Urgent Care Provider in Texas - Little Spurs Pediatric Urgent Care

Understanding Insurance Terms: Co-Pays, Deductibles and Facility Fees

  • April 1, 2016
  • 91
  • 2488

*not a patient

At Little Spurs we accept many kinds of insurances including Medicaid Superior, TRICARE, and BCBS. A full list can be found here: https://www.littlespurspedi.com/insurance.php

With health insurance becoming more expensive, many policies now have higher co-pays and deductibles in order to maintain the same premium. So what is a co-pay? The co-pay is the payment set by the insurance company in the patient’s policy and is determined by the type of service the patient is seeking (broken bones, sickness, or routine physicals). For physicals, there may be no co-pay while if you go to your doctor for an illness, there may be a co-pay.

The co-pay for an urgent care will be higher than your primary doctor but lower than an emergency room. The co-pay for an emergency room visit can be several hundred dollars. This is to discourage its use for non-emergent issues.

After a patient seeks medical care they then will receive a statement from their insurance company to explain what the insurance policy will cover. On this EOB (explanation of benefits) the patient will see the charge by the facility, the contractual amount the insurance company will pay, and what the patient is responsible to pay.  This is where the term deductible comes into play.

The deductible is the amount the patient will have to pay out of pocket until the insurance policy will begin to kick in. If the patient’s insurance policy has a high deductible, which most do, the total amount of the contracted fee will be passed onto the patient. High deductible policies have resulted in more out of pocket expense for the patient. As one may surmise, insurance companies love high deductible policies because very few people reach their deductible, saving the companies money.

So it is very important to ask whatever doctor or facility you visit, if they are contracted with your insurance company. They will always say they take your insurance, but if they are not contracted, the total fee charged will be passed onto you if your deductible is not met. Or if your deductible is met, then they can balance bill you which is the difference from what the insurance did cover.

This comes to the final term, facility fee. If the doctor, urgent care, or emergency room is affiliated with a hospital network they may charge a facility fee. This fee is to cover the cost of general operations of the building and employees. Many insurance companies do not cover facility fees, unless the care is actually on the grounds of a hospital and is in an emergency room. Many non-affiliated and affiliated urgent cares and emergency rooms now charge a facility fee. This fee can be from a couple hundred dollars to over a thousand dollars. Those fees are passed directly to the patient or can be balanced billed if some of the fee is covered by your insurance policy. It is also not uncommon that the doctor may be contracted with your insurance company but the facility is not. So one must be very specific when asking whether the doctor and facility are contracted. You may be in for a very unpleasant surprise when you receive your bill.

At Little Spurs Pediatric Urgent Care, we do not charge a facility fee and we try to be up front with the patient’s out of pocket expense. Unfortunately, some insurance companies do not have the information readily available, so it is important to call your insurance company to find that information when possible. To see what insurances we are in network with go to https://www.littlespurspedi.com/insurance.php.

-Thomas Spurgat, MD, MBA, CEO

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