When an insurance company is asked to send the payment directly to the physician instead of the patient is referred to as?

Over the past decade, out-of-pocket healthcare expenses have more than doubled for the average American. Many people are choosing high-deductible health plans in order to save on monthly premiums, but this change puts a higher burden on their wallets when it comes time to go to the doctor or fill a prescription. Doctors have been slow to change their internal billing practices in the past, but now they find themselves swimming in a sea of their own unpaid bills. Many providers are switching to point-of-service collections to curtail their losses, asking patients to pay for services before leaving the office. While the movement may not make everyone happy, it may be the only way to keep doctors in business.

What are Point-of-Service Collections?

There are many interpretations when it comes to point-of-service (POS) collections. Doctors and hospitals may refer to their POS collections as time-of-service, upfront, or front-end collections. In general, a provider who participates in POS collections will ask for payment of a proposed service sometime before the service is rendered, up to the time the patient is discharged or leaves the office.

POS collections ask everyone to pay, from patients who pay solely out-of-pocket to those who are insured and need to pay either a deductible, copay, or coinsurance amount. POS collections can also include prior balances or payment plan payments. Most hospitals and medical providers who conduct POS collections accept cash, checks, and credit card payments.

Why Does My Doctor Want Money Upfront?

With insurance premiums and deductibles continually rising, more and more Americans are having trouble paying their medical bills. According to the Academy of Healthcare Revenue, providers have a 70% chance of receiving payment at the time of service if they request it – but only a 30% chance of collecting it after a patient leaves the building. Since so many people are unable to pay their balances, many providers have started to question if they can even stay in business.

The reimbursement rates that doctors receive from insurance companies are also constantly changing. When you combine this reimbursement uncertainty with patient non-payment, many providers are left struggling to pay their office bills. Office space, utilities, technology, medical equipment, and staff are all necessary for patient care – but these items all cost money.

By moving to the POS collection model, providers are finding that they can spend less time billing patients and more time treating them. Many doctors and hospitals are even adopting payment plans as a way to help patients cover costs, similar to other industries that deliver higher-dollar products and services. While some patients may dislike the trend, it is allowing doctors to stay in business.

How Does My Health Insurance Work?

The traditional model of copays is quickly going out of style. Most patients now deal with health insurance that features either a high deductible or coinsurance – or a combination of both. Deductibles and coinsurance do not negate monthly premiums, though; they are paid on top of them.

• Deductibles – A deductible is the amount of money a patient must pay out-of-pocket before their insurance pays anything. These out-of-pocket expenses include prescriptions, sick visits, hospital stays, and medical procedures. For example: If you have a $8,000 deductible, that means that you must pay $8,000 in medical expenses before your health insurance will begin sharing your costs.

• Coinsurance – Often after a patient meets their deductible, their insurance company still only pays for a portion of their bills. Coinsurance plans split the patient and insurer responsibility based on a percentage. Typically, patients will have to pay for 10-20% of a service out-of-pocket (or more) while the insurance company pays the remaining percentage.

The Comprehensive Primary Care Policy

At CPC, we ask our patients with policies featuring annual deductibles to pay $100 on the day of their office visit. This $100 goes toward paying down the patient’s out-of-pocket costs associated with the visit and also contributes to paying down the patient’s deductible as a whole. Once a patient can show us that they have met their deductible for the year, we no longer collect the $100. Annual physicals are also not subject to this fee as long as patients follow the guidelines set forth by their insurance plans.

We have decided to implement the $100 POS collection fee for several reasons:

1. Patient Budgeting: The POS collection helps patients budget their medical spending based on services needed, and it also spreads payments out when they are still coming entirely out-of-pocket. Instead of receiving a bill for services all at once, a patient can pay $100 upfront and then the remainder when it is billed.
2. Office Budgeting: Knowing that we can count on a steady revenue flow helps us operate our office more smoothly and efficiently. Although we still work closely with patients and their insurance policies, the POS collection ensures at least a partial payment for services even when the insurance company is not yet liable.
3. Insurance Company Compliance: The agreements patients enter into with their insurance companies are legally binding contracts. By collecting a patient’s financial obligation, we are merely doing our part to enforce the previously agreed-upon contractual terms.

We understand that rising medical costs can make health care seem unaffordable for some people. CPC is committed to helping our patients ease this burden in whatever way we can. With our $100 POS collection, we can save money on billing services – keeping the prices for our services down for our patients. We want everyone to receive the highest-quality care available, and we will help you with insurance claims whenever we can. If you have any questions regarding your personal insurance coverage, feel free to contact us at any time. Let CPC help with your health in well-being in 2017; set up an appointment today!

Health insurance protects you from financial losses due to illness or injury. In exchange for your payments, known as premiums, your insurance company promises to pay for some or all of your health care services.

Health Insurance Terms

• Allowed amount – The maximum dollar amount an insurance company will pay for a given procedure or service. If a provider has a contract with an insurance company, the provider and the insurance company negotiate an allowed amount for each service or procedure. If a provider has a contract with a health insurance company, then the health insurance company considers the provider in-network and will not charge more than the allowed amount for a given procedure.
• Authorization – Your signature and pertinent information recorded on the form NC State requires you to sign in order to release your medical information either to yourself or to a third party. You may fax, mail or hand-deliver this form.
• Benefits – Medical expenses that your health insurance policy covers.
• Claim – Your formal request to your insurance company for their reimbursement of your medical benefits.
• Co-Insurance – The percentage of covered expenses you share with your insurance company.
• Co-pay or Co-payment – The dollar amount you must pay toward the cost of a benefit. Usually paid at your doctor’s office visit.
• Deductible – The dollar amount of eligible expenses you must pay during each policy year before benefits are payable by the insurance company.
• Exclusions – Medical and other expenses that your health insurance policy does not cover.
• Existing Creditable Coverage – Health insurance coverage other than University-sponsored health insurance plan that covered you before you came to NC State. Usually defined quite broadly, existing creditable coverage includes almost all group and individual health plans, Medicare, Medicaid, CHAMPUS, the Indian Health Service, a state health benefits risk pool, Federal Employees Health Benefits Plan (FEHBP), the Peace Corps Act, or a public health plan. Most faith-based plans do not meet the definition of creditable coverage. However, students may still request a waiver using these plans, but it may be denied.
• FERPA – FERPA stands for the Family Educational Rights and Privacy Act. This United States federal law applies to any student who either attends or has attended NC State. The United States Department of Education provides a summary of FERPA.
• Hard waiver requirement – The University of North Carolina Board of Governors’ requirement that students who have existing creditable health insurance coverage must BOTH provide evidence of their health insurance coverage to their respective universities AND waive coverage under the University-sponsored health insurance plan.
• Health care provider – Any person or entity that provides health care services. A provider could be a doctor, a physician’s assistant, a counselor, a licensed nurse practitioner, a hospital, or a physical therapist, just to name a few. Health care providers are usually licensed by the state in which they practice medicine.
• HIPAA – HIPAA stands for the Health Insurance Portability and Accountability Act of 1996, a U.S. federal law. HIPAA protects patients’ rights regarding #personal health information (PHI). The United States Department of Health and Human Services offers a summary of HIPAA.
• In-network – A provider or health care facility that is part of a health insurance plan’s network. In general, insured individuals pay less money out-of-pocket when they see in-network providers.
• Invoking criteria – The three conditions that, if you meet them all, mean that the State-level Health Insurance Requirement applies to you.
• Medical record – Legal documentation of your visit to a health care provider, the treatment you received and your payment for services.
• Network – A group of doctors, hospitals, and other providers with whom a health insurance company contracts to provide discounted services to insured individuals.
• Out-of-network – Describes a provider or health care facility which is not part of a health plan’s network. In general insured individuals usually pay more money out-of-pocket when they see out-of-network providers.
• PHI – PHI stands for protected health information, or any confidential information that identifies you. PHI may be oral or recorded in any form or medium a health care provider, health plan, public health authority, employer, life insurer, school, university, or health care clearinghouse creates that relates to past, present or future payment for the provision of health care to an individual.
• Premium – Money you pay your insurance company in exchange for insurance benefits
• Provider – Any person or entity that provides health care services. A provider could be a doctor, a counselor, a hospital, or a physical therapist, just to name a few. Providers are usually licensed by the state in which they practice medicine.
• Underwriter – A company that guarantees financial support for a health insurance policy.
• Usual, Customary & Reasonable (UCR) – The average charge for a given procedure or service. Typically based on the provider’s local area. If a provider is out-of-network, then there is no contractual agreement on how much he or she can charge for a given procedure. To help manage cost, insurance companies will often process out-of-network claims based on UCR. If the provider’s actual charge exceeds UCR, then the patient could be responsible for the difference between the UCR and actual charge amounts.

Difference Between Co-Insurance and Deductible

If your health insurance company says a covered benefit “applies to deductible and co-insurance,” you must pay the amount of your deductible. Your deductible is a declining balance. You must pay the amount of your deductible before your insurance company begins to reimburse you for medical expenses.

After you have paid your deductible, then you only need to pay co-insurance, or a portion of your medical expenses. Your health insurance company pays the rest. Under most health insurance plans, there is a limit to the amount of co-insurance you have to pay. This is known as an “out-of-pocket maximum.” In general, you pay your deductible and co-insurance directly to the doctor’s office, not to the insurance company.

Co-Pays or Co-Payments

You pay a co-pay (or co-payment) at the doctor’s office. A co-payment is a fixed amount of money that you pay when the doctor delivers (or renders) services to you. Co-pays DO NOT count toward your deductible or co-insurance. Depending on your insurance policy and on the kind of doctor you see, the amount of your co-pay may not always be the same. For example, you might pay a $20 co-pay to see a Family Practitioner, but you might pay a $50 co-pay to see a specialist, such as an Oncologist. In general, if the doctor’s title has “ist” at the end, the doctor is a specialist and not a primary care doctor.

Example In-Network Claim Under UNC System Health Insurance Plan (Deductible Not Yet Met)

If you have not yet met your deductible, the example below illustrates how your claim might break down. The dollar amounts in this example are for illustrative purposes only. Actual dollar amounts will vary depending on the service(s) you receive and the provider(s) you see:

Explanation of Above Claim

Because you pay a co-pay at your doctor’s office visit, your co-pay is deducted first: $250-$20 = $230. Next, your deductible applies: $230-$200 = $30. Your co-insurance applies next. You are responsible for 20% of $30, or $6. Your insurance company is responsible for 80% of $30, or $24. Therefore your total responsibility is $20 + $200 + $6 or $226.

Example In-Network Claim Under UNC System Health Insurance Plan (Deductible Met)

If you have met your deductible, the example below illustrates how your claim might break down. The dollar amounts in this example are for illustrative purposes only. Actual dollar amounts will vary depending on the service(s) you receive and the provider(s) you see:

Explanation of Above Claim

Because you pay a co-pay at your doctor’s office visit, your co-pay is deducted first: $250-$20 = $230. Because you have met your deductible, your remaining balance is $230. Your co-insurance applies next. You are responsible for 20% of $230, or $46. Your insurance company is responsible for 80% of $230, or $184. Therefore your total responsibility is $20 + $46 or $66.

Example Out-of-Network Claim Under UNC System Health Insurance Plan (Deductible Not Yet Met)

If you have not yet met your deductible, the example below illustrates how your claim might break down. The dollar amounts in this example are for illustrative purposes only. Actual dollar amounts will vary depending on the service(s) you receive and the provider(s) you see:

Explanation of Above Claim

Because you pay a co-pay at your doctor’s office visit, your co-pay is deducted first: $250-$20 = $230. Next, your deductible applies: $230-$200 = $30. Your co-insurance applies next. You are responsible for 30% of $30, or $9. Your insurance company is responsible for 70% of $30, or $21. Therefore your total responsibility is $20 + $200 + $9 or $229, but you may owe more money if the doctor charges more for a service than the insurance company allows.

Example Out-of-Network Claim Under University-sponsored Health Insurance Plan (Deductible Met)

If you have met your deductible, the example below illustrates how your claim might break down. The dollar amounts in this example are for illustrative purposes only. Actual dollar amounts will vary depending on the service(s) you receive and the provider(s) you see:

Explanation of Above Claim

Because you pay a co-pay at your doctor’s office visit, your co-pay is deducted first: $250-$20 = $230. Because you have met your deductible, your remaining balance is $230. Your co-insurance applies next. You are responsible for 30% of $230, or $69. Your insurance company is responsible for 70% of $230, or $161. Therefore your total responsibility is $20 + $69 or $89. Please contact the Student Health Insurance Office if you have any questions at:  or 919-515-2563.