Adding a Patients value of benefits that you got from checking their eligibility is what determines if we lose money on a visit, or collect the proper amount. Because a lot of visits are telehealth, we do not have much interaction with the Patient and therefore need to account for these things properly. 



📚Resources Needed



🚀 Tips & Tricks

  • Go through each one of the Insurance Eligibility Check articles. If you do not have a good grasp on this, you will have an issue with this. You need to understand this! 
     
  • If something with the insurance doesn’t make sense, call the Patient to confirm.
     
  • Here is a great video to better understand the difference between Copay, Coinsurance, Deductible, etc. 
     
  • Here are the main actions your doing: 
    1. Searching insurance eligibility
    2. Understanding what the Patient responsibility
    3. Updating Patient demographics
    4. Addressing any possible hiccups


       

💰 Patient Responsibility Matrix

Insurance Type / Scenario Typical Patient Responsibility When to Collect How to Collect Safely (Front Desk Guidance) Notes & Best Practices
1. Standard PPO/Commercial Plan – Copay Only Fixed copay (e.g., $20–$40 per visit) At check-in Collect full copay amount as listed on insurance card. Post to “patient payment.” Confirm visit type matches copay benefit (routine or primary care). No additional collection unless procedures/labs done.
2. PPO Plan – Copay + Deductible (mixed benefit) Copay for office visit plus deductible/coinsurance for add-on services Copay at check-in, remainder after EOB Collect copay upfront. If performing extra services (labs, injections), note that additional costs may apply once insurance processes. Never double-collect copay and deductible for the same base visit. Deductible applies only to the extra codes.
3. Coinsurance Plan (e.g., 80/20) Patient owes a percentage (e.g., 20%) of allowed charges After EOB, or estimate and collect partial upfront If you know the contracted rate, collect an estimated 20–30% deposit. Adjust/refund after EOB. Explain to patient: “Your plan covers 80%, leaving approximately 20% as your responsibility. We’ll collect an estimate today and reconcile after insurance.”
4. High-Deductible Health Plan (HDHP) – No HSA 100% of allowed charges until deductible met At check-in (estimated) Collect estimated charge for CPT code (e.g., $100–$150). Use payer portal to check remaining deductible. Label as “Deposit toward deductible.” Reconcile when claim finalizes. Refund if overcollected.
5. High-Deductible Health Plan with HSA 100% of allowed charges until deductible met, but patient pays with HSA funds At check-in (estimated) Collect full or partial estimated charge using HSA card or other payment method. Always call it a “deposit toward estimated out-of-pocket cost.” Patient can use or reimburse themselves from HSA. Refund promptly if overpayment occurs.
6. PPO Plan – Deductible + Coinsurance (e.g., $1,500 ded, 80/20) Patient pays 100% of allowed charges until deductible met, then 20% coinsurance after At check-in (if deductible not met) or post-EOB Check deductible status in portal. If not met, collect the expected allowed rate (e.g., $120). After deductible met, collect coinsurance (e.g., 20%) after EOB. Track deductible progress per payer portal. Educate patients that both portions apply at different times.
7. Preventive Care (Annual Physical, AWV, Screenings) $0 — fully covered under ACA (no copay, deductible, or coinsurance) No upfront collection Do not collect any payment. If non-preventive issues arise and a separate E/M is billed (modifier 25), then collect that portion post-EOB. Split billing documentation is key (preventive + problem visit must be clearly documented).
8. Secondary Insurance or Coordination of Benefits (COB) May reduce or eliminate patient balance Wait for both EOBs Do not collect until secondary insurance processes unless patient prefers to prepay and be refunded. Verify both insurances are active. Make sure COB is updated to avoid premature billing.
9. Medicaid (Primary) Typically $0 or small copay ($1–$5) At check-in if required Collect state-specific copay. Verify Medicaid eligibility at each visit; copays vary by state/program.
10. Medicare + Supplemental Plan Usually $0 after supplement pays After EOB if secondary active Wait for crossover payment before billing patient. Don’t bill patient unless secondary denies or applies deductible.
11. Out-of-Network / Self-Pay Full charge (no contract rate) Upfront (before service) Collect full payment at time of service unless you have a written payment plan. Provide Good Faith Estimate (GFE) per No Surprises Act for self-pay or uninsured patients.



⏪ Upfront collections (Amount added to Copay)

Plan Type Amount entered in Copay field Why Notes
Copay-only plan Full copay Patient obligation known and fixed Don’t collect more until EOB
Coinsurance plan Coinsurance % of allowed amount (Allowed amount = $175) Reasonable estimate Add the coinsurance % in the insurance notes. Adjust after EOB
High Deductible (with or without HSA) $20 Prevent bad debt Deposit because they have high deductible. Will know full amount owed after EOB. 
Mixed copay + deductible plan Copay only initially Deductible uncertain Bill remaining after EOB
Self-pay (no insurance) Full estimated charge Prevent write-offs Offer same-day discount if compliant



 

⚒️ Examples

  1. Copay is the only thing that is owed. 






    In this example, you can see that there is a deductible of 1000, and a copay of $25. In the coverage overview, you will see that it states for a PCP the copay is 25. Therefore, we will add $25 in the copay field. 


     

  2. Patient has Coinsurance



    In this example, you can see that there is a deductible that has been met, and a coinsurance is 20%. Therefore, we will add 175*.20 = $35 in the copay field. 



     

  3. Patient has High Deductable

In this example, you can see that there is a deductible that has not been met, and a coinsurance is 40% (Doesn’t mean anything in this case). This means the Patient is more than likely fully responsible for the visit. We should put $20 in the copay field to collect a deposit.