2 Coinsurance

Example

• Let us consider a 20% coinsurance. This means the insurance company will cover 80% of the allowed amount, while the remaining 20% will be the patient’s responsibility.

• Imagine a patient visits the doctor, and the insurance allows $500 for the services performed. Since the patient has already met their deductible and there is no copayment in the contract, only the coinsurance applies. With a 20% coinsurance, the patient is responsible for $100 (20% of $500), while the insurance covers the remaining $400 (80% of $500).

Actions

• First, we need to verify the status of the claim. This can be done by checking the status through the insurance web portal or by calling the payer, as we need the Explanation of Benefits (EOB) of the claim.

• If we call the payer and find that the claim has been paid along with some coins, we must collect key details, including the allowed amount, paid amount, check or EFT number, payment date, Coinsurance amount, claim number, processed date, the name of the representative, and the call reference number. In addition, we must request a copy of the Explanation of Benefits (EOB) through the available method, whether by mail, fax, or email.

• After receiving the EOB, we will either post it ourselves or forward it to the person responsible for posting payments.

• Before billing the coinsurance amount to the patient, we must confirm whether there is any active secondary insurance. If a secondary policy exists, we verify the eligibility and then send the claim to the secondary payer.

• Sometimes, especially in the case of Medicare, the insurance will automatically crossover the claim to the secondary payer. In this scenario, we wait up to 30 days, and if no response is received from the secondary insurance, we then contact them and take the necessary action.

• If there is no secondary insurance, then we release the claim to the patient.