Why did we get a bill after a visit that only had a copay?
Often the copay pays for the visit itself and nothing more. Labs, imaging, procedures, facility charges and out-of-network providers may each show up as a separate bill.
What is behind the short answer.
The short answer is above. These are the details that decide it for a specific plan.
The copay covers the visit
The flat amount at the front desk is for the office visit. Other services can be billed on top and fall under the deductible or coinsurance.
Labs and imaging are often separate
Tests sent to an outside lab or an imaging center can come from a different provider with a different bill, and possibly a different network status.
Facility fees
Care delivered at a hospital-owned location can carry a facility charge in addition to the provider charge.
What to do
Read the explanation of benefits from the carrier first. If a charge looks wrong or a provider was billed out of network unexpectedly, call the carrier or your benefits team.
Why a bill can arrive after a copay.
The $30 paid at the desk covers the visit. A lab charge billed separately can fall under the deductible or coinsurance. Here is how a $320 charge splits.
Illustrative figures. The Explanation of Benefits shows the real split. Compare it to the bill before paying.
What the rules say.
Every figure and requirement in this section traces to the federal sources listed at its end. This is general information, not legal advice.
Emergency care is protected
Under the federal No Surprises Act, a patient who receives emergency care may be charged no more than the usual share they would owe for a participating provider. This applies even if the emergency room is outside the plan’s network, and it extends to most care needed after the patient is stabilized.
Some out-of-network providers at in-network facilities are protected
Planned services at a participating hospital, its outpatient department or a surgical center get the same shield. A physician’s office that is independent of a hospital outpatient department does not.
Ground ambulances are not covered
Federal protection extends to air ambulance rides. Ground ambulances sit outside it, so unless a state law says differently they can send a bill at non-network rates.
Signing a consent form can waive the protection
A provider may ask a patient to sign a notice and consent form. Signing gives up the surprise-billing safeguards, and a patient can say no. Complaints go to the No Surprises Help Desk at 1-800-985-3059.
Sources: CMS: Know your rights with insurance
What Michigan adds when a bill is a surprise.
Michigan has a surprise billing law of its own for plans the state regulates. The points below describe what it offers a patient who receives a bill after a visit.
A Disclosure Form Before Scheduled Care
For a scheduled service, the provider must deliver a disclosure form no later than 14 days ahead. It warns that insurance may not pay for everything and includes a good-faith estimate of the total cost.
Emergency Out-of-Network Bills
When emergency services are out of network, the provider and the insurer settle payment between themselves, not the patient. Certain payment disagreements between those two can be taken to binding arbitration.
Self-Funded Employer Plans Follow the Federal Rule
The state law reaches insurers that DIFS regulates. Self-funded group plans sponsored by private employers generally fall under the federal No Surprises Act instead.
Where to Get Help
Begin with the insurer. If the matter is still open, phone DIFS at 877-999-6442 on weekdays between 8 a.m. and 5 p.m., or file a complaint at Michigan.gov/DIFScomplaints.
DIFS help line: 877-999-6442 · DIFS: surprise billing guide | DIFS: new health insurance protections
We help employees read the bill.
If a bill does not look right, our service team can go through the explanation of benefits with the employee and, where appropriate, help with a billing dispute or an appeal.
Related pages.
The Copay, Explained in Plain Terms
A copay is a fixed dollar amount an employee pays for a specific service, such as a primary care visit or a prescription.
Staying Available After Open Enrollment
Plan confusion does not end when enrollment closes.
Denied Claims and Appeals
What to do when a claim is denied and how appeals work.
Avoiding Group Health Insurance Plan Confusion
The full guide to helping employees understand their group health plan.
Questions that come up next.
Quick replies to the follow-up questions employees raise next, each linking to its own page.
Who should an employee call about a claim they do not understand?
A good first call is the member services line printed on the ID card; the representative can walk through how the claim was handled. If it still makes no sense, the employee should contact their benefits contact, who can review the plan documents and the explanation of benefits.
Is coinsurance the same as a copay?
No. A copay is a set dollar amount for a particular service, while coinsurance is a percentage of a covered service’s cost that the employee pays once the deductible has been met.
Do copays count toward the deductible?
That varies by plan. Copays count toward the deductible on some plans and not on others. They generally do count toward the out-of-pocket maximum for covered in-network care, but check your plan documents to be sure.
Ready? Send us your renewal, or talk it over with someone first. There is no charge and no commitment.
This is general information only, not legal or tax advice. For plan-specific questions, consult the plan documents or the carrier.
Send us your renewal.
You will hear whether it looks competitive, where we see room to improve, and which five questions we would raise with your carrier. It costs nothing and commits you to nothing.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents, plus two more for groups of 50 or over. Nothing beyond that, since each extra item only delays the review.
An independent employee benefits consulting firm. We look at the entire benefits program — cost, plan performance, risk and administration.
Switch to CFH. Unhappy with your broker? Your employees won’t notice. You will. →
Cookies on This Site
We use cookies to keep the site working properly and to understand how it is used. You can decline anything that is not essential. See our Privacy Policy for the detail.
- Essential — needed for the site to load and for you to move around it. These cannot be switched off.
- Analytics — tell us which pages get read, so we know what is worth writing more of.
- Advertising — set by third parties such as ad and social platforms to measure and target campaigns.