Quick Tips: Co-pay vs. Co-insurance

Copay:

This is a set rate that the client will pay regardless of what CPT code you bill.

Co-insurance:

A percentage of your contracted rate that the client will pay.

If the client has a deductible to meet, they will pay 100% of your contracted rate before the co-insurance kicks in. Once the deductible is met, the insurance company will pay the larger portion of the co-insurance.

Once the deductible is met, the insurance company will pay the larger portion of the co-insurance and the client will pay the smaller portion.

Some common co-insurance rates are 15% 20% or 30% (all portions the client pays).

Example:

Client’s benefits look this:

Deductible of $500 with $200 met

Co-insurance of 20%

Your contracted rates:

90791: $200

90837: $100

Client fees would be $200 for the first session (90791) and $100 for the second session (90837) then their deductible would be met and they would pay 20% of your 90837 rate or $20 with insurance paying the rest ($80).

I would use this script when e-mailing and explaining the client their benefits:

Hi John,

I checked your insurance benefits and you have a deductible of $500 with $200 met with a 20% co-insurance. Since I am in-network with your insurance you will have a discounted fee of $200 for the first session, $100 for the next session then $20 for sessions after that until your deductible resets. Please let me know if you have any questions and I look forward to meeting you!

Here’s a quick video (FB Live) that I did explaining the difference between co-pays and co-insurance and what that can mean for your clients.