Insurance & Billing

A deductible is an amount a patient pays for covered healthcare services before the insurance plan pays the remainder owed. The only exception to this is for preventative services. For example, with a $5,000 deductible, the patient pays the first $5,000 of covered services.

After the deductible is paid, most patients will pay a copayment or coinsurance for covered services. The insurance company then pays the remaining balance. Please also note:

–    Many plans pay for certain services, like a checkup or disease management programs, before you’ve met your deductible. Check your plan details.

–    All Marketplace health plans pay the full cost of certain preventive benefits even before you meet your deductible.

–    Some plans have separate deductibles for certain services, like prescription drugs.

–    The insurance will process claims at their allowable rate (this is what Epic Care has negotiated as their fee) and if there’s a deductible that hasn’t been met may turn over the entire balance to patient responsibility.

• The insurance will do this until the patient’s stated deductible amount is met. This means the insurance doesn’t pay; they will just process the claim and apply the allowable as patient responsibility.

Out of Pocket (OOP) refers to healthcare expenses that must be paid directly. For example, in an 80/20 plan the insurance will pay 80% of their allowable and the patient will have a 20% co-insurance. For a $100 service, the patient will pay $20 dollars out of pocket.

–    The patient will continue to pay their percent amount for each claim until their stated Out of Pocket is met.

–    Once the patient meets the plan OOP the insurance will pay 100% of all claims for the remainder of the policy year.

With Medicare only, a 20% co-insurance coverage will apply to all charges. This means the insurance plan will pay 20% of every service/claim. There is NO Out of Pocket or Stop Loss.

Medicare Advantage takes the place of Medicare. The advantage plan will administer the patient’s Medicare benefit. Medicare Advantage will often have specific deductibles and out of pocket expenses. Patients cannot have both Medicare and Medicare Advantage.

Medicare supplement is provided in addition to Medicare. Epic Care bills Medicare as the primary insurer. The remaining balance will be applied will be billed to Medicare supplement. There are many different supplements that exist. Not all plans cover the remaining at 100% after Medicare. Some plans have deductibles, coinsurance, and copays of their own.

Some plans have specific copay only, while some plans have no liability at all. Every plan is specific. Epic Care checks benefits on all patients receiving services not limited to scans, procedures or treatment.

Share-of-cost patients have a monthly spend down or SOC they are required to pay each month to be eligible for any Medi-Cal coverages. This amount is calculated by Medi-Cal and can be any amount. For example, if the patient has a $500 SOC. They will have to pay for $500 of services in the month for the remaining services to be paid for by Medi-Cal in that month. This is a cycle and repeats every 1st of the month.

Patient Advocate (PA) estimates are based on the patient’s individual plan details. The PA looks at the patient’s plan benefits, and if the patient has a deductible/out of pocket (OOP). The PA then evaluates how much has been met to date of both the deductible and the OOP. That information is compared to the allowable rates for their actual insurance (if available) to calculate how much will be covered by their insurance and how much will be applied to their deductible or coinsurance. These are always estimates based on the most recent available figures.

PA usually estimates from the current date to 2 weeks out, never more. This date is based on the referral due date.