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11 months ago · by · 0 comments

How does an health insurance company know how much you’ve paid?

How does a health insurance company know how much you’ve paid toward your deductible? Seems like an easy thing to fake. I got question today regarding how does a health insurance company know how much you’ve paid. Now that why I decided to clear it here for all insurance clients. How does a health insurance company know how much you’ve paid

How does an health insurance company know how much you’ve paid?

For an example regarding how does a health insurance company know how much you’ve paid: It’s the first day of your plan year so you have your full $1000 deductible left to meet. You go to your doctor and get a $200 procedure done. Your doctor sends a claim to your insurance company for the $200. The insurance company subtracts $200 from your deductible amount (leaving $800 remaining to be met) and sends the doctor a reply stating that you have not met your deductible yet so the full $200 is due.

The doctor sends you a bill for $200. You now need to get a $800 procedure done but haven’t paid your first bill yet. You get the $800 procedure done by the same doctor. The doctor sends the claim to your insurance company.
This time the insurance company lets the doctor know that you owe the full $800 (since that is what you had left to meet your deductible), but that now your deductible has been met for the remainder of the plan year. The doctor now sends you another bill for the $800. At this point the insurance company considers your $1000 deductible fully met, yet you haven’t paid anyone a single cent. It is now up to your provider (the doctor) to collect the money you owe him.

Regardless of this, your future services will have your benefits applied since your deductible has been met. This is what many people don’t understand about deductibles: they are not the amount you have paid, they are the amount of debt you’ve accumulated. *Please note that the above is a simplistic example meant to explain the basics of how deductibles work.

Because of communication between a provider and the billing department of the insurance company.  When your new benefit year rolls around your deductible amount is placed in their system.  This is communicated to your provider, and lets them know that your (e.g.) $100 deductible has not been met and the first $100 is on you.  If the provider doesn’t properly account for your deductible, they would be paying your deductible and not you… The chances of a doctors office or pharmacy NOT taking into account the amount of deductible communicated to them is pretty small.  If you wanted to commit fraud you would need to get the collusion of a provider to report to the insurance company you received a procedure and paid your deductible when in fact you didn’t…and that kind of cooperation is not easy to obtain.

Therefore, it did not include contract discounts, in-network vs. out-of-network services, or any other factors that would complicate the issue. Please contact your insurance company if you have concerns about your policy. Hope here now the question regarding how does a health insurance company know how much you’ve paid is clear now but if you have still any question about how does a health insurance company know how much you’ve paid than place comments. We will reply you according to your question about “How does a health insurance company know how much you’ve paid”. Thanks for reading about How does a health insurance company know how much you’ve paid. .

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