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Sickness billing format for Procurement

are you having difficulty understanding how to calculate the patient's liability or are you confused about the real differences between co-pays co-insurances and deductibles when you're looking at payment breakdowns in this video we're going to look at a few examples on how to calculate patients liability through the lens of reimbursement let's head in [Music] hi my name is jasmine i have more than two decades of healthcare experience on the business side of healthcare and with this space i look to alleviate the stress and confusion on the business side of healthcare let's look at this examples of patients co-pays coinsurances and deductibles okay guys so in this first example we are looking at deductibles so patients who have deductibles in our patients we've got two different patients here with two different services they have two different types of deductibles one has a one thousand dollar deductible and our patient two has a five hundred dollar deductible so when we're looking at our patient our blue patient here there's a cpt code that was billed and the build amount for that procedure assigned by the provider when they submitted the claim was 500 500 was not paid by the insurance company because the allowed amount ing to the fee schedule and the fact that this particular patient's service was in fact covered by their policy that amount is 250 dollars so in this instance we're going to say the patient's covered at 100 percent and they are going to reinverse 100 of the services if the patient does not have a deductible in this instance the patient has a 1 dollar deductible so because patient has a one thousand dollar deductible the insurance company versus rather than paying 250 dollars they apply that 250 to the patient and the patient is responsible for paying that 250 directly to the provider or organization that build the service okay which means that when the we get the explanation of benefits from the insurance company when the provider and the patient receive it it's going to reflect and zero dollars having been paid to the provider for this particular service so insurance company for patient blue is not going to be paying the provider organization instead the patient is paying the provider or organization for the service okay so let's scroll down and look at our green patient down here so our green patient down here instead of having a 1 000 deductible that they have a 500 deductible and so that 500 deductible here is for a perce is being applied to a procedure code that was billed in the amount of three thousand dollars so for that amount that was billed two thousand was allowed by the insurance company and so because the patient's deductible is only five hundred dollars the patient pays that deductible directly to the provider or organization that five hundred dollars justin is in our first example however because the allowed amount is two thousand dollars the fifteen hundred dollars remaining is now paid to directly to the provider by the insurance company because the provider is contracted with this insurance company the pr the payer will send the payment directly to the provider organization that billed the service and the patient is now in needing to pay that 500 if they have not covered it already they need to write 500 i was going to say write a check they need to or send a payment of 500 um directly to that provider or organization so in this instance the insurance company did send a payment but the patient is also liab liable for a proportion of the allowed amount that 500 that goes into the two thousand dollars allowed all right so that's our deductible example let's move on to some coinsurances and copay examples so deductibles are different than copays and coinsurances and i'm going to link below a video that takes you through the differences between co-pays co-payments and deductibles and if you have anything to add to this discussion about copay's coinsurances and deductibles or ways that you like to explain it to other people to break it down and simplify it please comment below i'd love to hear i'm always wanting to hear really fun ways that people are helping them themselves understand and interpret um these this very complex topics that we have in healthcare in the us okay back to our example so when we're looking at an example of a copay copays are typically zeros after a flat dollar amount so patients don't typically have a uh ten dollar and seventy cent copay right or a twenty dollar or twenty five dollar and fifty cent copay it's typically a round number so in our example today our round number is 25 so there's no coins involved for most copay i've not seen any ever i so i'll just say there's no coins involved for copays so it's typically a 30 45 25 10 so on okay so in our example our patient has a 25 copay okay so for this service 500 was billed 250 was allowed no deductible patient does not have a deductible yay and the patient has a 25 copay so that means that the insurance company is going to require the patient to cover 25 of this 250 allowed amount so our provider can be paid the 225 dollars okay so this check from the insurance company will be paid or this payment will be sent to the provider or organization for 225 the 25 copay is something that the patient is responsible for at time of service in most cases it's collected as soon as the patient checks in for services to be rendered so that 25 copay needs to be paid from the patient directly to the provider or organization okay so copay black and white a little bit clearer because it's just a flat number that just gets deducted from our allowed amount okay coinsurance is a little different so in our example today our patient has a 25 percent co-insurance which means that the insurance company would typically pay 100 and instead they're chipping away and saying instead of us paying 100 you patient are responsible for 25 of that responsibility so the insurance company will only pay 75 percent okay so patient is paying 25 percent not 25.25 so our examples here i intentionally made them the same so that you can hopefully see the differences so our patient has this procedure code that was billed for 200 for 500 250 is allowed and 25 of 250 is 62.50 okay so 62.50 and again i went back to my coins remember i said when when a patient has a co-insurance there's usually coins involved co-pays are usually flat amounts okay so in this case i've got 50 cents so i pretty much know i'm looking at a co-insurance so without me even seeing that the patient has a co-insurance just by looking at an eob or in my accounting software i can usually tell that there was a co-insurance versus a co-payment amount okay so my patient has a 25 of 250 needs to be covered by the patient okay so notice the difference between the amount patient is responsible for with a copay 25 copay versus a 25 same exact allowed amount and service that was billed but the liabilities completely different so it's really important you understand there is a major difference between co-pay and co-insurance even though they sound the same at the start of the word okay so when i see that patient has 25 you collect that 62.50 and then the insurance company or payer will reimburse their provider that 187 dollars and 50 cents which is 250 minus 62.50 that is the amount being paid to the provider okay i know these topics are very complex so we'll be doing many more examples but i hope those examples helped you if you still have questions i want to know so please comment below and let us know about what things are confusing you what topics are are you having trouble with and where are you losing me or are you losing your interpretation of these things when you're dealing with patients all right thank you all so much and we'll see you in the next video [Music] you