Insurance Scenarios
Below are examples of how insurance can influence the direct cost to the patient.
Example:
Test/Procedure: MRI of the Neck without contrast
CPT Code: 70540
Gross Charge: $3,638.10
Example 1
The patient has a deductible of $250 and his or her coinsurance is 20% up to $500. This patient plan allowed amount will reimburse up to $800 of a provider charge.
| $3,638.10 |
MRI Gross Charge |
| -$2,838.10 |
Provider Contractual Allowance
(The portion the medical provider deducts from gross charges per contractual agreements with insurance provider) |
| -$800 |
Payer Allowed Amount
(Total amount the insurance payer will allow, including the patient responsibility) |
How much would the patient owe?
| $800 |
Payer Allowed Amount |
| -$250 |
Patient's Deductible |
| = $550 |
|
| x .2 |
20% Coinsurance |
| = $110 |
Total coinsurance owed |
Patient responsibility:
$250 (deductible) + $110 (coinsurance) = $360
Insurance plan will pay = $440
Example 2
The patient has met his or her deductible for the year and the coinsurance is 20% up to $500, the patient has met $250 of their coinsurance. This patient plan allowed amount will reimburse up to $800 of a provider charge.
| $3,638.10 |
MRI Gross Charge |
| -$2,838.10 |
Provider Contractual Allowance |
| -$800 |
Payer Allowed Amount |
How much would the patient owe?
| $800 |
Payer Allowed Amount |
| x .20 |
20% Coinsurance |
| = $160 |
|
Patient responsibility:
$0 (deductible already met) + $160 (coinsurance)
Insurance plan will pay = $640
Example 3
The patient has met his or her deductible for the year, along with meeting all coinsurance (out-of-pocket responsibility). This patient plan allowed amount will reimburse up to $800 of a provider charge.
| $3,638.10 |
MRI Gross Charge |
| -$2,838.10 |
Provider Contractual Allowance |
| -$800 |
Payer Allowed Amount |
How much would the patient owe?
Patient has no obligation for deductible or coinsurance amount because he or she has met the deductible and coinsurance maximums for the year.
Patient responsibility:
$0 (deductible already met) + $0 (coinsurance)
Insurance plan will pay = $800
