Wait, why do I owe patient responsibility?

A frustrating aspect of most health insurance...

Most common reason

Your deductible hasn't been met for a sick or follow-up visit

The unfortunate reality is that for all sick and follow-up visits (i.e., anything that isn't specifically a well-child visit), most insurance companies will not cover any of the cost until your deductible has been met. This means that until you pay your full deductible out-of-pocket (say $3,000), you will be required by the insurance company to pay for all sick and follow-up visits.

Note: Your deductible doesn't apply to well-child visits - these visits are typically covered by insurance regardless of how much you've spent towards your deductible.

Patient responsibility can be confusing because a co-pay is often visible on your insurance card (say $20), but your insurance plan will pass on a much higher cost to you after the claim has been processed.

In these cases, we are contractually required to bill you the patient responsibility that the insurance company determines. The amount can vary depending on the nature of the visit and your specific health plan, but the typical out-of-pocket cost for a sick visit is in the $100 - $150 range.

Less common reason

Your insurance company refuses to cover certain clinically important procedures

Thankfully this is less common, but some insurance companies refuse to cover procedures that are clinically important and pass along the cost to you as patient responsibility. A typical example of this is the postpartum depression screener. The research tells us that it's important for pediatricians to screen parents for postpartum depression in the months after a child is born, but some insurance plans have a different view.