Confused about insurance?

Insurance can be confusing…let’s uncover the common terms.

The big question of insurance is always, “how much am I going to owe?” You would think it would be obvious, but it’s not to the layman. Insurance terms and policies can be so confusing that sometimes people do not seek out the treatment they need or they aren’t aware and cause themselves to get a surprise bill from the doctor. We do not want you to be confused or caught by surprise so we are here to uncover some common terms!

*Please note that this information is generalized. If you have any questions or concerns it is best to call your insurance company and speak to a representative. I will add common insurance’s customer service lines at the end of this blog post.

Once a year, you have the opportunity to elect new benefits. This year, we want you to be armed with a bit of knowledge.

Words like deductible, co-pay, co-insurance, pre-certification, referrals, and EOB are used everyday in a medical office setting. Are any of these familiar to you? Perhaps deductible is the most frustrating term. If you are lucky enough to have a high deductible plan, that means you could be responsible for a lot through out the year!


This is the total amount you pay out of pocket. There are several deductibles that apply to your plan: individual, family, and out of pocket max. Sometimes, you even have a separate deductible for different services.

Let’s say you have an individual deductible of $1,000. Once you meet your $1,000 deductible, the only thing that you will be responsible for is your co-pay or co-insurance.

You may also have a family deductible, which is a total of out-of-pocket expense paid by the entire family. If this deductible is met (typically because a member of the family has major medical expenses that exceeds their deductible), then your individual deductible does not apply to you for the remainder of the year. You should only be responsible for your co-pay or co-insurance.

The out-of-pocket max is the magic number that says you are no longer responsible for any costs that you may accumulate. It is the amount you spent on your deductible, co-insurance, and/or co-pays that totals an agreed upon number with your insurance company.

Some individual’s policies have a separate deductible for Physical Therapy which is lower than their individual deductible! Are you one of those lucky people?


This number is independent of your deductible. Typically, if you have a co-pay you will not have to meet your deductible for this to come into effect. Let’s say you have a $3,000 deductible, but a $25 co-pay for each physical therapy visit. You will only pay your co-pay and not have to worry about any further expense for that visit. This amount is collected at time of service.


This is an out-of-pocket expense that calculates a percentage of your visit cost. You would have agreed to this number when electing your insurance policy. It is usually 10, 15, 20 or 30%.  This number comes into effect after you have met your deductible. For example, you have met your $3,000 deductible for the year and you come in for a physical therapy visit that is billed for $100. You have a 20% co-insurance, which means you would owe the provider $20 for that visit. This amount also applied to your out-of-pocket max and family deductible. Keep in mind that each visit may vary depending on the services received.


The Explanation of Benefits (EOB) is the document that you receive from your insurance company that outlines your cost for a medical visit. It is important to look at these and understand them. It could save you money if the provider tries to charge you more than they should.

Below is an example of EOB’s in different situations provided by WebPT. Here are some important definitions to understand when reading an EOB:

  • CPT Code- this is a code used by medical offices that describes the services rendered. The insurance company and provider have a contract that determines how much the provider can be paid for this service. This leads to the adjusted amount.
  • Adjusted amount- The adjusted amount is the amount the provider must write off because of their contract. You do not owe this amount.
  • Patient Responsibility- This is the amount your insurance says you owe to the provider according to your contract with the insurance company. They may also denote in this section what the amount applies to: deductible, co-pay, or co-insurance.
  • Insurance paid- This is the amount your insurance pays the provider.

Insurance 1: Patient has not yet met his or her annual deductible. Therefore, the patient is responsible for 100% of the allowed amount.

Date of Service CPT Code Units Billed Amount Adjusted Amount Patient Responsibility Insurance 1 Paid
03/01/2017 97110 1 50.00 20.04 29.96 0.00
03/01/2017 97140 2 100.00 44.58 55.42 0.00
TOTALS: 3 150.00 64.62 85.38 0.00


Insurance 2:Patient owes a 20% coinsurance for PT services.

Date of Service CPT Code Units Billed Amount Adjusted Amount Patient Responsibility Insurance 2 Paid
03/01/2017 97110 2 100.00 42.47 11.69 45.84
03/01/2017 97140 2 100.00 54.19 9.31 36.50
TOTALS: 4 200.00 96.66 21.00 82.34


Insurance 3:Patient owes a $10 copay for PT visits.

Date of Service CPT Code Units Billed Amount Adjusted Amount Patient Responsibility Insurance 3 Paid
03/01/2017 97140 2 100.00 30.00 10.00 60.00
03/01/2017 97535 1 45.00 45.00 0.00 0.00
TOTALS: 3 145.00 75.00 10.00 60.00



Still confused? Leave a comment and we will see if we can clarify anything. And if in doubt, always feel free to contact your insurance’s customer service. Here are a few of the most common ones: 

Blue Cross Blue Shield:

Customer Service Telephone Numbers
Federal Employees 1-800-492-8872 M-F (7 a.m. – 6 p.m. Central)
Blue Advantage, BlueRx & C Plus with PMD 1-888-543-9212
(TTY 711)
M-F (8 a.m. – 8 p.m. Central)
Individual & Family Products 1-888-267-2955 M-F (9 a.m. – 5 p.m. Central)
Business & Employer Plans 1-855-525-7283 M-F (8 a.m. – 4:30 p.m. Central)
All Other Blue Cross Members 1-800-292-8868 M-F (7:00 a.m. – 6 p.m. Central)



1-800-MEDICARE General Medicare information, ordering Medicare booklets, and information about health plans. Toll Free: (800) 633-4227
Tricare: 1-800-444-5445

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