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Paying Your Bill

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Helping You Understand What Your Health Insurance Requires You to Pay

As a courtesy to our patients, St. Joseph offers the assistance of counselors to help you understand the financial obligations required by the insurance program you participate in. Our aim is to help you understand what your insurance program requires you to pay out of pocket for services. Our counselors also can assist those patients who do not participate in an insurance program.

How does health insurance work?

Imagine you have a $100,000 heart surgery, which is a covered medical expense under your health insurance plan, and let’s say this health insurance plan has a $1,000 annual deductible, 20% coinsurance after deductible, and $2,000 out-of-pocket limit per year.

What is a Deductible?

Typically, a deductible is the amount of money you must pay each year before your health insurance plan starts to pay for covered medical expenses. So with a $100,000 heart surgery bill, you are responsible for paying the first $1,000. After this $1,000 deductible is met, the insurance company will pay a percentage of the bill in what is called the coinsurance.

What is Coinsurance?

Typically, coinsurance is a cost-sharing requirement where you are responsible for paying a certain percentage and the insurance company will pay the remaining percentage of the covered medical expenses after your deductible is met. For a health insurance plan with 20% coinsurance, once the deductible is met, the insurance company will pay 80% of the covered expenses while you pay the remaining 20% until your out-of-pocket limit is reached for the year.

What is Out-of-Pocket Limit?

Typically, the out-of-pocket limit is the maximum amount you will pay out of your own pocket for covered medical expenses in a given year. For a plan with a $2,000 out-of-pocket limit, you will pay a $1,000 deductible and $1,000 coinsurance while the insurance company covers the remaining $98,000 of the heart surgery bill. Even if you are hospitalized again in the same year, the insurance company will pay 100% of your covered expenses.

What is Co-payment?

Typically, a co-payment or co-pay is a specific flat fee you pay for each medical service, such as $30 for an office visit, after which the insurance company often pays the remainder of the covered medical charges. Let’s say you are not feeling well and went to see your doctor who charges $200 for the office visit. If your insurance plan has an office visit co-payment of $30, then you will only be responsible for the $30 and the insurance company will cover the remaining $170.

What is a physician charge?

A physician charge is a nationally recognized approximation of the cost of a physician, anesthesiologist and/or surgeon required to perform a service or procedure. Physician charges are generally billed separately from hospital charges and are paid directly to the St. Joseph Medical Group.

Why are two separate prices, a physician price and a hospital price, listed on the price list?

Most hospitals are financially separate from their doctors, so when they provide price information, it usually does not include the doctors’ charges. St. Joseph combines the hospital and physician charges to make it easier for patients to understand their bills. Insurance companies require that we send two bills, one for the doctors’ work and one for the other resources (nurses, lab technicians, supplies, drugs, etc.).

What is a facility charge?

The cost of the accumulation of services provided for a patient’s care in the hospital or during outpatient surgery.

What is a DRG?

DRG stands for Diagnosis Related Group. A DRG is only assigned to an inpatient hospital service. DRGs are universal groupings used by Medicare and most insurance companies to clarify the type of inpatient care a patient receives. Insurance companies use the DRG code, along with a diagnosis/CPT code and the length of the inpatient stay, to determine payment and reimbursement for claims.

What is length of stay?

The time period a patient is hospitalized from the admitting date to the discharge date.

What is a CPT code?

CPT stands for Current Procedural Technology. A CPT code is a five digit code used by all hospitals, physicians and insurance companies to identify a type of service or procedure.

What is Medicaid?

Medicaid is a state program that provides hospital and medical coverage for people with low income and little or no resources. Each state has its own rules about who is eligible and what is covered under Medicaid. Some people qualify for both Medicare and Medicaid. For more information, you may contact First Source at 610-378-2277 to assist you with an application.

What is Medicare?

Medicare is the nation’s health insurance program for people aged 65 and older. Certain people younger than 65 can qualify for Medicare also, including those with disabilities, people with permanent kidney damage, people with amyotrophic lateral sclerosis (Lou Gehrig’s disease). The program helps with the cost of health care, but it does not cover all medical expenses or the cost of most long-term care. Medicare is financed by a portion of payroll taxes paid by workers and their employers. It also is financed in part by monthly premiums deducted from Social Security.

What if I have insurance?

Can I tell how much I will have to pay from the price list? No. The amount they pay is specific to their insurance plan. Because there are so many different insurance plans, we have to look up the specific insurance contract to give the patient an estimate. Our PreRegistration department can assist patients in determining what their costs will be. Insured patients who want an estimate of out-of-pocket costs should contact us at 610-378-2121.

What if I don’t have insurance?

We can assist patients in determining if they are eligible for Medicaid. Patients who don’t qualify for Medicaid may be eligible for other financial assistance. Does St. Joseph offer a discount? Yes. Patients who are uninsured may be eligible for a 50% Self Pay discount. Contact a financial counselor at 610-378-2351.

What if a procedure is not listed on the web site?

Charges for many common, high-volume procedures are listed here. More information will be listed in the future. Contact our Pre-Registration Team at 610-378-2121.