Paying a copayment at your doctor’s office doesn’t necessarily mean you won’t receive a medical bill later on. It’s common to get a bill even after covering your copay, which can be confusing. Here’s an explanation of why you may still owe additional costs beyond the copay and what to expect if a bill comes your way.
What Is a Copay and Why Do You Pay It?
When you visit a doctor, urgent care, or emergency room within your health insurance network, you typically pay a copay upfront. A copay is a fixed dollar amount you pay at the time of service, like $25 for seeing a primary care physician or $50 for visiting an urgent care clinic.
The copay covers just a portion of the total charges for that visit. It goes directly to the provider to help cover their costs. You pay a copay whenever you access healthcare services, whether it’s for a checkup prescription refill or procedure.
Copays allow you to pay a predictable amount rather than waiting to find out the full cost after your claim is processed. They provide revenue to doctors while giving you, the patient, financial protection because your total liability is capped
Why You May Still Get a Bill After Paying Your Copay
Here’s why paying the copay doesn’t necessarily mean you’re done paying for that medical visit
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The copay doesn’t cover the full charges. Your doctor submits a claim to your health insurer with the total charges for everything done during your visit. This is almost always more than the simple copay you pre-paid.
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Your deductible or coinsurance may apply. In addition to the copay, you’re responsible for 100% of costs until your deductible is reached, then a coinsurance percentage after that.
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Not everything may be covered. Your insurance might not cover some services the doctor performed, so you’d owe the uninsured portion.
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Claims take time to process. It takes a while for your health insurer to process the claim from your doctor and determine how much is covered.
So in short, you may get a bill later because the copay only satisfied part of the total charges. The rest is dependent on your deductible, coinsurance, and what ends up being covered after the claim is processed.
How Bills Are Calculated After Your Copay
When your doctor submits the claim to your health plan, here’s what happens:
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They bill your insurance the full charges for everything done during your visit. This is the “allowed amount.”
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Your insurer reviews to determine which charges are approved and covered.
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If you haven’t met your deductible for the year, you owe 100% of the approved cost.
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Once your deductible is met, you pay coinsurance on the approved charges, such as 20%. Your insurance pays the rest.
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If the total bill includes services that aren’t covered, you owe that portion in full.
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Any amount previously paid for the copay is applied to the total you owe.
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You receive a bill for the remaining balance. This is why you get a bill even after paying the upfront copay.
As an example, say you visit the doctor for a sore throat. The total billed charges are $250. Your copay is $25, so you pay that upfront. Your deductible hasn’t been met yet, and your coinsurance is 20%. Here’s how it plays out:
- Total billed charges: $250
- Your copay paid already: $25
- Approved charges after claim processed: $200
- You owe 100% since deductible isn’t met: $200
- Minus copay already paid: -$25
- Remaining amount you owe: $175
In this situation, you’d get a bill for $175 even though you already paid a $25 copay. This represents the portion beyond the copay owed based on your deductible and coinsurance.
When to Expect Medical Bills After a Copay
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Do I have to pay a copay for every doctor visit?
FAQ
Does copay count towards bill?
Most plans do not count your copays toward your health insurance deductible. However, your plan might. Every year, health plans change their cost-sharing rules to find new, more cost-effective, and more consumer-friendly ways to set these rules. How do you know for sure?.
Why do I still owe after copay?
It’s likely that you owe a deductible or coinsurance amount, or that services other than the office visit code were provided. This is especially likely with a specialist. Your insurance should provide an explanation of benefits explaining the charges.
How do copays work?
Every time you see your doctor or fill your prescription, you have to pay a flat fee called a copay. When you go to the doctor because you hurt your back or because you need more medicine for your child’s asthma, the amount you pay is called your copay.
Can you pay a copay later?
You might have to pay the copay when you check in at the doctor’s office before you can see the doctor. Alternatively, some doctor’s offices may bill you for the copay after the visit. Preventive care is typically exempt from cost-sharing structures like copays, thanks to the Affordable Care Act (ACA).
Should you pay a copay before or after a doctor visit?
You may remember going to the doctor and paying a $15 or $20 copay before or after the visit. Copay amounts can vary depending on the provider and service. If your health plan has copays, you’ll know exactly how much you need to pay before you go to the doctor. This can help you plan how to pay for your care.
Do I owe a copay or a deductible?
There may be both copays and deductibles in your health plan. Depending on the services you get, you may only have to pay one or the other. There may be a set amount you have to pay for some services, like seeing your primary care doctor. This could be $10 or $20.
Do you have to pay a copay on your health insurance card?
Most insurance companies or healthcare providers require copays to be paid at the time of service. Oftentimes, the copay amount is printed directly on your health insurance card. It might even list the prices for different services, like a visit to the primary care doctor and services for specialist care.
Does a health plan have a copay?
Copay amounts can vary depending on the provider and service. If your health plan has copays, you’ll know exactly how much you need to pay before you go to the doctor. This can help you plan how to pay for your care. For most plans, your copay does not apply toward your deductible.
Do I have to pay a copay for my Medicine?
Sometimes, you may have to pay for all of your medicine until you reach your deductible. Most of the time, you’ll have to pay a copay for each visit or refill, or until you reach your health plan’s annual out-of-pocket maximum, which could be several thousand dollars.
What is the difference between Copay and deductible?
Copay vs. You pay a certain amount of money for medical care before your insurance plan starts to pay for it. This is called your deductible. Like, you might have to pay a $2,000 deductible every year before your insurance will cover certain medical care or drugs.
