Frequently Asked Questions

The amount of money someone must pay out-of-pocket before coverage kicks in. Deductibles are usually set at rounded amounts (such as $1000, $2000, etc.). Typically, the lower the premium someone pays, the higher the deductible they have. Deductibles reset annually. Many plans reset on January 1st, but depending on the employer, they may reset at a different point in the year. When someone's deductible resets, they are generally responsible to pay the contracted rate toward their services until their deductible is met again.

This is usually a set percentage of the total bill and is the amount of money someone owes after they hit their deductible. If a policy has a 10% co-insurance, the client will pay 10% of the total allowable charges and the insurance company will pay 90%. 

The amount a client must pay each date of service. This amount is usually standard across a plan (i.e. the patient pays a $20 copay each visit, regardless of what service was performed). Oftentimes, someone who has a copay will have that amount regardless of whether there is a deductible. However, sometimes someone must meet their deductible in full before their copay amount applies. This varies from plan to plan. 

The maximum amount of money someone will pay toward deductibles, co-insurance, and co-pays for a plan year. After the out-of-pocket max is reached, the insurance company will pay 100% of allowable charges for the remainder of the plan year. 

A provider is considered in-network when they have contracted with a particular insurance company and agreed to the insurance company's rates. Please see the in-network insurances tab for a list of insurances each EMH provider is in-network with. 

A provider is considered out-of-network (OON) when they have not contracted with an insurance company. OON providers are not bound to an insurance rate and can collect the full fee for service. Sometimes people will have OON benefits and can be reimbursed for their healthcare costs, but other times they cannot. 

This occurs when a client has more than one health insurance plan, with one being considered "primary" and the other being considered "secondary."

This process is something that individuals with dual coverage need to do. The insured needs to contact their insurance plans and conduct a coordination of benefits (COB) to determine which insurance plan is primary and which is secondary, as well as make sure that both plans are aware of the arrangement and can process claims together. 

Commercial plans are ones that someone typically obtains through an employer or another method of buying into their own insurance. This is different from governmental plans such as Medicaid or Medicare, even if those plans are managed by a commercial provider. 

A recoupment is also known as a clawback. This occurs when an insurance company has paid for a service but later determines that they should not have paid and/or it was not a covered service. This can also happen if the insurance company audits records or requests additional documentation and it is determined that a service was not medically necessary.

This is a detailed invoice containing all necessary information for an out-of-network claim to be submitted by a patient to their insurance company in order to receive a reimbursement from their insurance plan. 

An Explanation of Benefits (EOB) is a detailed account of what was billed to your insurance, what your insurance is paying, and what you owe.