By Martine G. Brousse (not AI!)
"The Medical Bill Whisperer"™
Patient Advocate, Certified Mediator
AdvimedPro
February 4, 2025
The “copay” is an important part of your insurance policy.
What is it? What should you know? Can you save $ ? Let’s explore
A. What is this “Copay"?
1. It is a set fee for some services that you can expect to pay at time of service, and even before the insurance receives and processes that provider’s claim/charge.
2. The amount varies by the type of covered service you might receive:
· Office visit
· Specialist consultation
· ER visit
· Hospital stay
· Some Scans
· Some Rx
· Some procedures or treatments
3. The Copay is usually considered part of your yearly “Out of Pocket” share of cost, along with deductible and co-insurance
4. Copays are usually credited toward that max Out of Pocket amount, but it all depends on your policy.
B. What to know
1. Out Of Network copays are often higher than those for similar services rendered by In Network providers
2. Once your yearly max Out Of Pocket share of cost has been met, you usually do not have to pay copays for the rest of the year…unless your policy says you do (sorry!)
3. A “copay” is NOT a separate charge, and therefore can neither be billed to nor be paid by your insurance plan. It is how (part of) the patient’s financial responsibility is labeled.
4. There is NO Copay for Preventive services/care, when rendered by an In Network provider, and even if you have not yet met a penny of your yearly Out Of Pocket.
C. Save $
1. Check, find out, ask:
· Call your insurance’s Customer Service rep
· Visit your insurance online portal or policy
· Check your insurance card
· Contact HR for clarification
2. Audit your EOBs:
· There is NO Copay for Preventive Services, when rendered by an In Network provider, and regardless of how much Out Of Pocket has been met
· Out Of Network Emergency services must be paid at the In network rate, so any Copay should be lowest (federal No Surprise Act mandate)
· Non-emergency Out of Network services rendered at In Network facilities must be paid at the In network rate, so any Copay should be lowest (federal No Surprise Act mandate)
3. Communicate with providers:
· Indicate you have met your yearly max share of cost to avoid paying Copays
· Request a refund if you paid a copay at the time of service, but your insurance EOB shows you do not owe one
· Beware of any “Copay” listed as a procedure or service, as it is not, and should be included in the cost of the main service.
In conclusion, “Ask and Verify” is a good strategy to follow when it comes to Copays.
Although amounts can be small, they tend to accumulate, and less scrupulous or organized billing departments might ask you for, or hold on to, funds which are not theirs but yours!
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2025 @ the medical bill whisperer 2025™
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