financial Policy: Copay vs. Deductible & Coinsurance (Office Visits + Procedures)
Why am I being asked to pay more than my copay?
Most insurance plans treat procedures differently than a standard office visit. Even when performed in the office, certain services may apply to your deductible and/or coinsurance rather than only a copay.
What is a Copay?
A copay is a fixed amount you pay for a covered service, often an office visit (evaluation and management).
Examples that commonly use a copay:
New patient visit
Follow-up visit
Discussion of symptoms, exam, plan, medication management
What is a Deductible?
Your deductible is the amount you must pay each year before insurance begins paying for many services.
If your deductible is not met, you may owe the insurance allowed amount (the discounted, contracted amount) for certain services.
What is Coinsurance?
After your deductible is met, many plans require you to pay a percentage of the allowed amount. That percentage is coinsurance.
Office Visit vs. Procedure
Office Visit (often copay applies): the provider’s evaluation, exam, and treatment planning.
Procedures (often deductible/coinsurance applies): separately billable services performed during your visit.
Common ENT examples include (not limited to):
Nasal endoscopy (scope exam sinus cavity)
Laryngoscopy (scope of the throat or vocal cords)
Ultrasound
Biopsy
Ear Cleaning
Cautery for nosebleeds
X-rays
Hearing Tests
Some in-office diagnostic tests or minor procedures
Important: You may have an office visit copay and also owe deductible/coinsurance for a procedure done at the same appointment.
Payments Due at the Time of Service
At check-in or prior to a procedure, we may collect:
Your copay (if applicable), and/or
An estimated amount toward your deductible/coinsurance
Estimates are based on insurance information available at the time. Final responsibility is determined after your insurance processes the claim.
Patient Responsibility
Insurance verification is a courtesy and does not guarantee payment. You are responsible for:
Copays, deductibles, coinsurance
Non-covered services
Any balance due after insurance processes the claim (based on contracted/allowed amounts)