Why did we get a bill after a visit that only had a copay?
Because the copay usually covers the visit itself and not everything billed around it. Lab work, imaging, a procedure, a facility fee or an out-of-network provider can each be billed separately.
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.
The figures and requirements below come from the federal sources cited at the end of this section. General information, not legal advice.
Emergency care is protected
Under the federal No Surprises Act, emergency services cannot be billed to the patient at more than the in-network cost-sharing rate, including at out-of-network emergency rooms and most post-stabilization care.
Some out-of-network providers at in-network facilities are protected
Non-emergency care at an in-network hospital, hospital outpatient department or surgical center is covered by the same protection. A doctor office that is not a hospital outpatient department is not.
Ground ambulances are not covered
The federal protections reach air ambulances, but ground ambulances can still bill out-of-network rates unless state law says otherwise.
Signing a consent form can waive the protection
Some providers ask patients to sign a notice and consent form. Signing it gives up the surprise-billing protection, and patients can decline. 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 its own surprise billing law for plans the state regulates. Here is what it gives a patient who is billed after a visit.
A Disclosure Form Before Scheduled Care
Providers must send a disclosure form at least 14 days before a scheduled service, warning that insurance may not cover everything, along with a good-faith estimate of the total cost.
Emergency Out-of-Network Bills
For out-of-network emergency services, the provider and the insurer, not the patient, negotiate payment. Certain payment disputes between them can go to binding arbitration.
Self-Funded Employer Plans Follow the Federal Rule
The state law applies to insurers DIFS regulates. Self-funded group plans of private employers generally follow the federal No Surprises Act instead.
Where to Get Help
Call the insurer first. If that does not settle it, call DIFS at 877-999-6442, Monday through Friday, 8 a.m. to 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.
When a bill does not match expectations, our service team helps walk through the explanation of benefits and, where it applies, supports 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.
Short answers to the questions employees ask after this one. Each links to its own page.
Who should an employee call about a claim they do not understand?
Start with the member services number on the back of the insurance card, which can explain how the claim was processed. If it still does not make sense, the employee should call their benefits contact, who can look at the plan documents and the explanation of benefits.
Is coinsurance the same as a copay?
No. A copay is a fixed dollar amount for a specific service. Coinsurance is a percentage of the cost of a covered service that the employee pays after the deductible is met.
Do copays count toward the deductible?
It depends on the plan. On some plans copays count toward the deductible and on others they do not. Copays generally do count toward the out-of-pocket maximum for covered in-network care, but confirm in your plan documents.
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