Navigating the Complexities of Medical Coinsurance

medical coinsurance

Are you wondering about how medical coinsurance can affect your billing process? As experts in avoiding denials in medical billing, PracticeForces can help you understand the role medical coinsurance plays in your billing and how to avoid complications.

To learn more, contact us today.


What Is Medical Coinsurance?

Medical coinsurance is the amount a patient pays for covered medical expenses after they’ve met their yearly deductible. The amount consists of a certain percentage of the medical costs shared between the patient and the insurance provider.

For example, if a patient has a 25% coinsurance rate and receives a $400 treatment, the patient pays $100 (400 x .25), and the insurance company pays $300 (400 x .75).

If the patient reaches their maximum out-of-pocket limit, they no longer require coinsurance, and the insurance provider covers all eligible doctor visits and medical expenses.


How Coinsurance Affects Medical Billing

In general, medical coinsurance shouldn’t affect how you bill your patients, but you should understand how it works in case they have questions about what certain treatments will cost them.

It also doesn’t require special medical coding modifiers since those depend on the type of treatment rather than the payment method.


Helping Patients Determine Costs

When you help patients understand their medical costs, you create a strong bond with them. This means they’re more likely to approach you with advanced care planning and other health concerns, and you keep a paying customer. Generally, patients require help understanding the different types of insurance payments.



A deductible is the amount a person must pay before they’re eligible for coinsurance. For example, if their family has a $5,000 deductible, they’ll need to accrue that amount in medical expenses before the insurance company starts sharing the cost.

Health insurance plans with high deductibles often have lower monthly premiums. A relatively healthy patient that doesn’t require much medical treatment can benefit from high-deductible plans.



Copays function much the same way as coinsurance but impose a flat fee rather than a percentage. Copays are popular for sharing the cost of prescriptions but may apply to other medical expenses as well. 

For example, if a patient has a $25 copay on all prescriptions, they pay that amount for each one, regardless of the cost. It helps the patients predict the costs much easier, as the total doesn’t vary with the cost of the service like a 20% coinsurance would.

Copays apply even before a patient reaches their deductible.


Out-of-Pocket Maximum

A patient’s maximum out-of-pocket limit dictates the most a patient will pay in medical expenses in a given calendar year. For example, while a patient might have a deductible of $2,000, their insurance plan might have a $10,000 maximum.


PracticeForces Helps Manage Difficult Medical Billing Claims

While medical coinsurance shouldn’t affect your medical billing, you’re now ready to help your patients understand the term. As a trusted provider of medical billing and medical practice consulting, PracticeForce can help you manage your healthcare organization. 

Whether you’re wondering about the allowed amount in medical billing or need help managing finances, we can help. Call (727) 202-5429 for the answers to all your questions.

Parul Garg, CEO and co-founder of PracticeForces, has significantly contributed to the growth of over 1,000 U.S. medical practices through her expertise in medical billing and coding since the company’s inception in 2003. With a background in Computer Science and an MBA in Human Resources, her leadership and AAPC-certified coding skills have been pivotal in managing the company’s operations effectively.

Related Posts

Why Are EHR Systems Key to Enhanced Billing?

Efficient billing is crucial for the smooth operation of medical practices, ensuring timely revenue generation and accurate financial records. In today’s healthcare landscape, Electronic Health Records


Do you want to streamline your reimbursements?

Subscribe for actionable tips and insights to grow your medical practice >

Call Now Button