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Please Explain Out of Pockets and Deductibles

As in yesterday’s topic, many clinic staff members seem to think that these two terms mean one in the same thing.  The results can be less than desirable if the difference between out of pockets and deductibles is not clearly understood.

In a nutshell:

Out of Pocket (OOP) Maximum: Maximum amount the insured must pay out of his or her pocket (other than premiums) before the plan pays 100% of covered expenses. Out of pocket may or may not include deductibles and/or co-pays.

Deductible: Amount the insured pays first before the co-insurance starts.

Example one: Patient is seen by the provider.  The VOB states that none of the $500 deductible has been satisfied at this time. The out of pocket amount of $3000 also has not been satisfied, and there is a 20% co-insurance.  The patient should be charged the allowed amount in full for the services rendered today.

Example two: Patient is seen by the provider.  The VOB states that the $500 deductible has been completely satisfied, only $700 has been applied so far to the $3000 out of pocket maximum, and there is a 20% coinsurance. The patient should be charged 20% of the allowed amount for today’s services.

Example three: Patient is seen by the provider. The VOB states that the $500 deductible has been satisfied, the $3000 out of pocket has been satisfied, and there is a 20% coinsurance.  Nothing should be collected from the patient today since the services are now covered at 100% of the allowed amount.

Be sure your staff has a good understanding of OOP maximums and Deductibles so that you do not end up saying, “OOPS!” in the end.

Understanding OOPs can Prevent an OOPS! Situation
Understanding OOPs can Prevent an OOPS! Situation