Unfortunately, No: The Hard Truth About Insurance

We’ve all been there: making insurance payments each month, covering our monthly premiums, and hopefully getting closer to meeting our deductible. However, the issue often arises with copays, coinsurance, and other out-of-pocket costs.

Generally, insurance does not cover everything. There are copays and other costs that vary based on numerous factors. Person A’s insurance may cover more than Person Z’s insurance, even when both receive the same services under similar circumstances. One person’s $9 copay is another person’s $90 copay. Same services. Same office. Different factors.

According to Healthcare.gov and other insurance resources, most health insurance plans include deductibles, copayments, and coinsurance, meaning patients are typically responsible for a portion of their healthcare costs even when they are insured. For more information, see:

• https://www.healthcare.gov/glossary/deductible/
• https://www.healthcare.gov/glossary/copayment/
• https://www.healthcare.gov/glossary/coinsurance/

It’s not always fair, and thankfully there are ongoing efforts to improve affordability, but overall, that’s how insurance works.

Unfortunately, not everyone seems to understand that insurance does not cover everything.

“I have insurance! I shouldn’t be getting charged for any of this!” exclaims a person.

But that’s just not how it works.

As mentioned before, coverage varies from person to person, but generally most insurance plans do not cover 100% of healthcare costs. Instead, they cover a portion of the cost of services, leaving the patient responsible for deductibles, copays, coinsurance, or other expenses.

Some exceptions do exist. Certain Veterans receiving care through the U.S. Department of Veterans Affairs (VA) may qualify for services without copays, depending on disability ratings, income levels, and eligibility status. More information can be found here:

• https://www.va.gov/health-care/copay-rates/

However, for those with non-VA coverage, it can sometimes be less expensive to pay out of pocket rather than go through insurance.

Programs such as sliding-scale fees help ensure continuity of care without the headache of navigating insurance billing. By removing the middleman and working directly with the provider, patients may find a more affordable and predictable payment structure.

Still, some people prefer the insurance route. Understandably so as what else are those monthly payments for?

However, it’s important to remember that insurance companies tend to protect their bottom line before anything else. They may cover services, but it’s important to find out exactly what they will cover before making an appointment.

In many cases, a sliding-scale fee may actually cost less than what your insurance would ultimately require you to pay.

A medical office can tell you what it charges for a service, but it generally cannot tell you exactly what your insurance company will charge you. That depends on your specific plan, deductible status, copays, coinsurance requirements, and other factors determined by the insurer.

Is this a way for a medical office to dodge responsibility?

Absolutely not.

We are more than happy to work with you on your individual needs and circumstances. The issue is that insurance companies do not always provide consistent reimbursement rates or patient cost estimates.

One of my favorite examples involved an insurance company stating that our services would cost a client $500 per session. We do not charge anywhere near that amount for an individual session.

That is why it’s important to ask questions before beginning treatment at any medical practice, therapy office, or healthcare provider. Depending on your insurance plan, you may end up paying significantly more than the provider’s standard rate.

Even beyond insurance and sliding-scale fees, there are programs that reimburse or discount services after the fact through rebates. In many cases, the office is not involved whatsoever. Receipts and proof of payment simply need to be submitted on time.

Because of this, it’s important to evaluate all of your options.

Insurance, a sliding-scale fee, or a rebate program may each be the best choice depending on your situation. The key is understanding the costs ahead of time and selecting the option that works best for you.