Do You Get Billed After a Copay?

You go to the doctor, pay your copay at the time of your appointment, and assume that covers your share of the costs. But then weeks later you get a bill in the mail from the doctor’s office. So what’s going on? Why are you getting charged extra after already paying your copay?

Getting billed additional amounts after paying a copay is common. There are a few key reasons this tends to happen.

How Copays Work

First, it helps to understand what a copay covers. A copay is the set amount you pay to receive a medical service, usually paid when you arrive for your appointment. Common copays are:

• $20 for a primary care physician visit
• $40 for a specialist visit
• $15 for a generic prescription

The copay covers just a portion of the total charges for your care. It does not represent the full amount your provider will bill to your insurance plan.

Your health insurance company negotiates discounted rates with in-network providers. The provider agrees to accept the insurance company’s negotiated amount as full payment for treating you.

But you are still responsible for paying your portion – the copay. The insurance company then pays the remainder of the negotiated charges directly to the healthcare provider.

Why Extra Bills Happen

There are a few key reasons you may get a bill from your provider even after paying your copay:

Time Lag

There is often a time lag between when you receive services, when the claim is submitted, and when your insurance processes the claim.

The typical flow is:

1. You visit the doctor and pay your copay.

2. Afterwards, the doctor’s office sends a claim to your insurance with details of your visit and services provided.

3. The insurance company reviews the claim and determines how much they will pay the provider based on your policy details.

4. You are sent an Explanation of Benefits (EOB) showing what the insurance paid.

5. If your copay did not cover your full patient responsibility, the provider bills you the outstanding balance.

This process can take weeks to complete. So you may leave the doctor thinking you paid your share in full, then get a bill later on once insurance has processed the complete claim.

Non-Covered Services

Another reason for extra bills is receiving non-covered services. Your copay was for a specific eligible service, like an office visit. But you may have received additional services that your policy does not cover, like cosmetic procedures or experimental treatments.

Since those services are not covered benefits, your insurance will not pay any portion of them. You would be responsible for 100% of those non-covered charges, beyond the standard copay amount.

Out-of-Network Providers

Seeing an out-of-network provider can also lead to additional bills. Your copay is based on the negotiated rate your insurance has with in-network doctors.

Out-of-network providers have no contracted rate with your insurer. They may charge significantly higher amounts for services. So your standard copay likely will not meet your full patient responsibility.

For example, an in-network doctor may charge $150 for a visit and have a $25 copay. But an out-of-network doctor could charge $300 for the same visit. You would owe the additional amount over the $25 copay you paid upfront.

Deductible or Out-of-Pocket Max

If you have a deductible on your plan, or have not yet met your annual out-of-pocket maximum, bills can arise after a copay.

For example, let’s say your plan has a $1000 deductible and 20% coinsurance after the deductible is met. If your visit charges are $150, and you’ve only paid $200 toward your deductible this year, you’d owe:

• $150 visit charges
• Less $200 deductible already paid
• $50 left to meet deductible
• Plus 20% coinsurance on $150 = $30

So you would get a bill for the $50 to go toward your deductible plus the 20% coinsurance, even after paying the copay upfront.

Out-of-pocket maximums work similarly – you could owe additional costs until you meet your annual limit.

Sample Billing Timeline

To summarize, here is a sample timeline that shows when you might get billed extra amounts after your initial copay:

• Visit Date: You see your doctor and pay $25 copay at the appointment.

• 1 Week Later: Doctor’s office sends claim to your insurance detailing $200 in charges for the services provided.

• 3 Weeks Later: Your insurance sends you an EOB showing they paid the doctor $100 based on your policy terms.

• 4 Weeks Later: Doctor’s office sends you a bill for the remaining $75 patient responsibility ($200 charges – $100 insurance payment – $25 copay you already paid).

• 6 Weeks Later: You receive a second EOB from insurance showing a $50 lab test charge that was not covered. No insurance payment was issued for the non-covered service.

• 7 Weeks Later: Doctor’s office bills you the $50 for the non-covered lab test.

This example shows how the time lag in claim processing, as well as non-covered services, can lead to bills long after your visit.

Tips to Minimize Extra Bills After Copays

While getting additional bills from your provider after you’ve paid your copay can be frustrating, there are steps you can take to reduce the likelihood of this happening:

• Know your policy details – Understand your deductible, copays, coinsurance, out-of-pocket max, covered services, and exclusions. Also know which providers are in-network vs out-of-network.

• Ask upfront – When scheduling an appointment, ask the doctor’s office to confirm they are in-network and the amount you will owe based on your specific insurance plan and policy.

• Get prior authorization – If you are receiving extensive, expensive, or specialized treatment (like surgery, therapy, diagnostics, etc.), contact your insurance in advance to get prior authorization and determine what your total patient responsibility will be.

• Don’t assume – Do not assume your copay covers your full responsibility. Expect that additional bills are a possibility depending on the treatment, your deductible status, network status of the provider, and your policy coverage details.

• Review EOBs – Carefully review all Explanation of Benefits statements from your insurance to understand what they determined as covered vs non-covered. Watch for any denied lines that you may get billed for.

• Compare bills – When you do receive a bill from your provider, compare it against your EOB to ensure the amounts match what your insurer already determined and paid.

• Negotiate – If you are billed for an amount you cannot afford, contact your provider’s billing department to discuss payment plans, financial assistance programs, or negotiating a lower balance.

• Meet deductibles/maxs – If you have high deductibles or out-of-pocket maximums impacting your costs, consider setting aside funds in a Health Savings Account to cover any bills after copays.

While you can take proactive steps to avoid or prepare for bills after copays, some amount of additional balances may be inevitable depending on your specific insurance policy. Understanding why they occur and keeping close track of notifications from your insurance company can help minimize confusion or surprise when bills do arise.