Copays, Deductibles, and Coinsurance

Episode Transcript

Speaker 1 (00:00):
Thirteen ten WIBA and full scope with Wisconsin's direct care doctor,
doctor Nicole Hemkiss. Of course, doctor Hemkiss comes to us
from Advocate, MD, a direct primary care practice with offices
four of them. One on the east side of Madison,
right on Fair Oaks ab west side the original, right
in Middleton on Glacier Ridge Road down in Janesville, right

(00:22):
at the for those folks in southern Dane County, right
in the Rock County area as well on ten twenty
one Mineral Point Avenue, and of course to do with
location in Fitchburg right at thirty two twenty Syene Road
just south of Madison. Beautiful, beautiful area. All four locations
almost said three, they're all four locations of Advocate EMPD.
Just fantastic clinics. And I mentioned the Sayine Road area.

(00:45):
It's nice little nature preserved down there. It's very relaxing
and doctor, do you get a chance just on a
little break, just kind of walk out, walk walk around
the neighborhood there by the nature preserve. You've got a
park right in that area too. That's a great spot
for you.

Speaker 2 (00:59):
Yes, year surrounded, I believe on three sides by the
nature preserve, and so we get a lot of the
wildlife that wanders in from over there.

Speaker 3 (01:07):
But yeah, it's a very pretty area, it is.

Speaker 1 (01:10):
And it's a great clinic as well, speaking of the
clinics of Advocate MD. Eight physicians working out of those
clinics and they are there for you. It's a great
day to learn more about Advocate MD and Direct Primary Care.
Even better, great day to become a member and make
an appointment. All you got to do is it's really
easy to pick up phone. Gave a call six two
six eight sixty two eleven. That's six A two six
eight sixty two eleven. Very very great model direct primary care.

(01:34):
And again you can learn more online ADVOCATESDPC dot com.
That's Advocates DPC dot com. Doctor. One of those areas
that we often kind of confuse the two and kind
of intertwine the two and think they're the same, which
are health insurance and healthcare, and there is a even
though a lot of times those are provided by the

(01:55):
same people, there is a there there is a very
very distinct difference between the two. Let's talk a little
bit about that.

Speaker 2 (02:04):
Yeah, you know, I think that we are so kind
of it's engraved in our heads that that health insurance.
You know, you have to have health insurance and that's
what gives you access to health care. And you know,
I think that that's something that's a relatively new concept
in the last you know, twenty years. I think, you know,
people were very used to paying cash for things back
in the day, but as health and health care became

(02:25):
more and more expensive, you need, we needed a mechanism
to pay for health care. So that's where health insurance
came along. So I think that being able to separate out,
you know, health insurance being a mechanism to pay for
health care is important, right because many people now are
paying more for their health insurance than they are paying
for their health care. Right you might be paying five

(02:46):
hundred to one thousand dollars a month for your health
insurance and you don't really go to the doctor, which
then then that enters into this question of like there's
something wrong here, right when we're paying more for the
health insurance and the actual cost of the care when
we go in to get it. So that's where kind
of brings us to this direct primary care and looking
at that as something separate from health insurance. But you know,

(03:09):
you still need to have some form of coverage, but
it's not the same as you know health care in
terms of when you go in to see the doctor,
when you get your blood drawn, you know, when you
have an urgent care emergency. You know, those things can
all be done outside the purview of health insurance.

Speaker 1 (03:27):
So we talk about that and kind of breaking that
down a little bit is people don't always understand like
the other area, so we think we pay for this stuff.
And I think I brought this up on the show.
It's probably been a while, but I remember the first
job I ever had where they offered healthcare, and I
remember thinking like I had the golden ticket, like, oh
my goodness, I'm paying for this thing now, and if
I need to see my doctor or if, gosh forbid,

(03:49):
something were to happen to me, I'm covered. I'm cool,
everything's good. And then you quickly realize, and this is
part of growing up. It's a lot more complicated and
it's a lot more expensive than you ever ever would realize.
Let's talk about some of the some of the basic
things to understand about healthcare and kind of what those
meanings are, things like copays, deductibles, what is co insurance,

(04:09):
all that fun stuff.

Speaker 2 (04:12):
Yes, you know, I think health insurance is, you know,
as we've talked about it, it's very complicated, you know,
and in many people, you know, the average person that
if you're not in the health care field, if you're
not in the health insurance field, you might not even
know kind of what your deductible is, what your copays
are until you actually have to use it.

Speaker 3 (04:30):
Right.

Speaker 2 (04:30):
So again, because many people aren't going to the doctor
a lot, you know, they're they're not having to figure out,
you know, what these different terminology means. But so the
copay is the thing that so some people have co
pay plans or non copay plans, and the copay is
the thing that you pay when you go in to
see the doctor. So usually it's twenty or forty dollars.
Usually when you go into see your primary care doctor,

(04:51):
you're paying different copays than if you were to go
see a specialist. Some people have co pays for things
like urgent care visits or emergency department visits, and that
would be much more expensive. But again, the thing that's
you know, I like to point out to people is
that even though you have a copayd plan, let's say
so let's say it's twenty dollars every time you go
to see a primary care doctor, and it's forty dollars

(05:12):
when you go to see a specialist. Just because you
have that copaid, that that does not mean that that
is covering the cost of everything that.

Speaker 3 (05:20):
You do when you go in to see that doctor.

Speaker 2 (05:22):
So once you see the doctor and they say, okay,
here's you know, I want you to get these three
or four labs, or I want you to get this
X ray done, or you know, let's say some other procedure.
I'm trying to think of what other die they might
do another diagnostic in the office there, and all of
that is not going to be in most cases covered
by your copaid. The labs will be treated separately, you know,

(05:44):
any sort of imaging will be treated separately. So you know,
you get you might have the false impression that oh,
it's only going to be twenty dollars when I go
to see this doctor, and then you get the bill
in the mail, you know, two or three months later,
where it's like it was five hundred dollars or you
know it could be more. You know that again, and
you know, might not include something like a facility fee.
You know, again, you might have the twenty dollars cope,

(06:04):
and then they might charge you a facility fee if
that structure is owned by a hospital, even if it's
not within a hospital. So there's all these kind of
hidden charges. So that's important to understand what your insurance
actually covers and what that cope actually covers. And then again,
you know, it's it's important to know if they do

(06:26):
order additional labs or a diagnostic test that's going to
be done there. Let's say at that at the same
clinic or at the same facility, will that be an
additional charge? And then you know ninety five percent of
the cases it will be.

Speaker 1 (06:39):
What is And I've never understood this and I have
to call my wife anytime I go to the dentist
and and they ask about insurance, and then they ask
about co insurance, and I'm like, what is this? Where
does that fit in? And obviously in the medical world
we talk about the cope, the deductible. What is co
insurance exactly?

Speaker 2 (06:57):
Tactor, Yes, And it's that's a good question. And it's
also good before we mentioned that is the deductible.

Speaker 3 (07:04):
So the deductible is the.

Speaker 2 (07:06):
Thing that you have to reach before your insurance, let's say,
quote unquote kicks in right. So some people have a
low deductible insurance policy. So nowadays that would be like
something like a five hundred dollars deductible. That used to
be very common, but nowadays it's it's less common. So
many people have four thousand and five thousand. You could
have a ten thousand dollars deductible. I was looking the

(07:27):
other day at an insurance policy and it was a
fifteen thousand dollars deductible. So basically, what that means if
I have where my deductible is. Again, in this I'm
kind of talking in generalization, but that means that you know,
everything I do up until that point, I am going
to pay out a pocket for. So the most of
the time, this is kind of if I don't have

(07:47):
a copay plan, that means that, you know, every time
I go in to see that doctor, if I again
get lab work done, if I, you know, need a
diagnostic test.

Speaker 3 (07:57):
If I need an MRI, if I need an X ray.

Speaker 2 (08:00):
All of those things I am going to pay out
a pocket for even though I have insurance. You think, well, well,
so what the heck is the insurance for then, so
I have insurance. But if I go in let's see,
you know, whether it's a primary care doctor or a specialist,
they send me to get an X ray. You know
that that office visit charge is five hundred dollars, the
X rays one thousand dollars. So if I have a

(08:21):
five thousand dollars deductible, I Am going to pay everything
out of pocket until I hit that deductible and that's
when the insurance kicks in. But then in many cases,
you also, as you mentioned Sean, you have to know
the terminology of co insurance. So many people will have
this co insurance, which means once they've hit the deductible,
you know, then it might say, okay, now you're responsible

(08:43):
for twenty percent. Now you're responsible for ten percent. So
even now I've hit my deductible, let's say I've hit
my thousand dollars deductible or my five thousand dollars deductible.
Let's say I then need to go into the emergency department,
and that emergency department charge was one thousand dollars, and
I have a twenty percent co insurance charge, so I'm

(09:04):
going to pay two hundred dollars of that thousand dollars charge.
And then lastly, many people have a max out of pocket.
So for some people the max out of pocket would
be the deductible, but many in many cases, it's not,
you know, because they have again this co insurance thing.
So you know, you might have a five thousand dollars
deductible and a ten thousand dollars max out of pocket.

(09:26):
So again I think all this it's it's a lot
of information, it's a lot of to process. It is
a lot, but it's good to know the facts of
what your insurance policy is actually covering, because for some
people they might work out the numbers and be like,
this doesn't make sense anymore, right if if I have
a fifteen thousand dollars high deductible plan, you know, you again,

(09:47):
you need to have what we always say with our patients,
and most of our patients ninety five percent of the
patients and advocate MD have some backup, whether that's a
high deductible insurance policy, whether that's health share. Some of
them have low deductible insurance policies, but you do need
something there in case you.

Speaker 3 (10:06):
Have a catastrophic thing happened to you.

Speaker 2 (10:08):
So you know, very unfortunate things like you know, you
need an emergency surgery, you need your gall bladder taken out,
you you know, have a diagnosis like cancer where you're
going to need to have cancer treatments or surgeries, you know.
So that is the stuff where it is very very expensive,
and it you know, potentially can bankrupt people. So you
need to have something in place for those sort of

(10:31):
unforeseen events that can happen. For the vast majority of
things that will happen to you in your life in
terms of your health care, though, those are things we
can handle in an outpatient setting. We can take care
of most of that within the primary care setting of
you advocate m D. And so we try to maximize
what we can take care of it in our practice.
And that's going to make it easier for patients, more

(10:53):
affordable for patients, more accessible for them to get in
for appointments, and it's also going to lower their out
of pocket right because, as we've talked about it, if
you can do the X ray with us rather than
do do it at the hospital system, or if you
can do the blood work with us rather than go
into the big health system lab, that's all going to
be cheaper for you to do it that way, regardless
of whether you're going through your insurance. Again, because if

(11:15):
you have a deductible, even if it's one thousand dollars,
that lab work's going to cost you four or five
hundred dollars, and in our clinic it might be twenty dollars.
So you want to kind of maximize. Patients in our
practice want to maximize what they're doing with us.

Speaker 1 (11:30):
Doc this morning with doctor Nicole Hemp because of Advocate MD,
and we talk about the clinic and you know, some
of the great benefits of being a member at Advocate MD,
And a lot of times when we talk about all
the services that are offered at Advocate MD and through
Direct Primary Care, people are like, it's got to be expensive.
Reality is it's not. It's actually a very affordable option
for you your family. Also, if you're an employer looking

(11:51):
for some great benefits for your employees, a great option,
check out Direct Primary Care. It's a great recruitment tool
as well and retention tool. If you offer something like that,
Employees really really like what they're able to do at
Direct Primary Care and Advocate MD. With Direct Primary Care
at Advocate MD. You can learn more online the website
ADVOCATESDPC dot com. That's Advocates DPC dot com. Great day

(12:11):
to make an appointment. Oh, I got to just pick
up phone game a call six eight two six eight
sixty two eleven. That's six oh eight two six eight
sixty two eleven. What about ACA and what about our
yearly visit? What is going on there? What do we
need to know? Some of the ins and outs when
it comes to costs, we'll find out from doctor Nicole
Hempkiss next as Full Scope continues right here on thirteen
ten wuib A thirteen ten WIBA and full Scope with

(12:34):
doctor Nicole Hempkiss, Wisconsin's directcare doctor. Of course, doctor Hemkiss
comes to us from Advocate MD, a direct primary care
practice for area clinics to right here in Madison Eastside,
West Side, also one right in Fitchburg for southern Madison.
And of course if you are in the Fitchburg area
or anywhere near the Voice, you can definitely get into
those three clinics. If you're in the Rock County area

(12:56):
southern Dane County, she's got a great clinic right on
Mineral Point AVA in Janesville. Great day, to become a member,
start to start seeing the doctors at Advocate MD. I
got to just pick up the phone become a member
six oh eight two six eight sixty two eleven. That's
six oh eight two six eight sixty two eleven. You
can learn more online Advocates DPC dot com. That's Advocates
DPC dot com. You can learn more about the clinics. Also,

(13:18):
as we're talking this week about insurance, you can learn
a little bit more as well about high deductibles and
other high deductible plans and other plans that can really
really benefit you, as well as health shares. As we
talk with doctor Nicole Hemkiss and doctor Aca, and I
do believe the first A and ACA is affordable.

Speaker 2 (13:40):
What happened there, Yes, So you know, I think the
basic premise behind the ACA, which a lot of us
endearingly call Obamacare, is that if we could expand health
insurance to more people, if we could, on paper, more
people had health insurance. Instead of eighty percent of the
population having health insurance, ninety percent has health insurance, that

(14:03):
would create an environment where more people had access to healthcare.
And again, I think this is based on the false
premise that health insurance equals healthcare, right, and so that
did happen. More people do have health insurance today than
they did ten years ago. But what it created, what
the ACA created was that it made health insurance more expensive.

(14:27):
You know, obviously every year health insurance becomes more expensive
by most accounts it. You know, the cost of premiums
is going up for individuals, you know, five to ten
percent a year. For companies, you know, closer to ten
to twenty percent a year, their premiums are increasing. The
other thing that it did, though, is so it shifted
the way it created this kind of false this facade

(14:49):
that you know, more people had health insurance, is that
it shifted more of the cost onto the consumer, onto
the patient. So now they're deductible is higher again, so
it you know, maybe previously it was more common for
people to have a five hundred dollars or one thousand
dollars deductible, and now they have a three thousand or
four thousand dollars deductible. So again that's that's shifting cost
to the consumer. The copays went up, so again instead

(15:11):
of maybe a ten or twenty dollars copay, now it's
a forty dollars or fifty dollars copay. Again, things like
the co insurance. All of these things shift more of
the cost on the consumer. So you know, if you
think about it on a very basic level, you think, oh,
this is this is great people have insurance or you
know again, I could think personally think, oh, you know,

(15:32):
I have my health insurance policy, so I'm good to
go now. But when you look at the reality of
it is that most patients are paying not only more
for their health insurance today than they used to, but
they're also getting a lot less out of it. So again,
you know, they if you have one of those higher
deductible insurance policies, you're paying for more out of pocket.

(15:52):
And the cost of all of those out of pocket
cost are you know, way more increased. You know. The
other kind of deceptive thing have you? I don't know
if you've ever experienced this, Sean, is you know you
get your once a year preventive care visit that was
part of the ACA. You know too, is that's a
requirement And I don't know, Sean, if you if do
you normally go in and see your doctor.

Speaker 3 (16:13):
Once a year?

Speaker 1 (16:14):
I do, and I remember, and this ties in perfectly
and I think I've told you this story before.

Speaker 2 (16:19):
Uh.

Speaker 1 (16:20):
One of the one of the other piece of advice
my wife gave me was unless you have anything important,
don't bring it up with you. That seems raw, but
there's a reason for that statement.

Speaker 2 (16:34):
Yes, So so what happened is, you know again, and
this goes back to medical billing and coding, which is
super complicated and confusing, you know, even for people in
the medical field. But the idea was that if if
they code this as a preventive care visit, you know,
your once a year annual permitive care visit, then that's okay,
that's covered with the insurance, and all insurance are required

(16:56):
to cover that one visit. But of course, what happens
during the visit, and and you know, I don't want
to present this as the doctor is doing anything fraudulent.

Speaker 3 (17:03):
They are not.

Speaker 2 (17:05):
Again many times they're not even the one coding the visit,
you know, some there's some other person in the billing
department doing that. But so you know, of course, during
the course of that visit, they're going to say, sean
of even having any headaches, how are you sleeping, any
stomach issues? You know, you know, how are you breathe
is breathing okay, or you have an allergies. You know,
ask you these kind of head to toe we call

(17:25):
that a review of systems. And you know, for most
people in those in those questions, maybe something comes up
like oh, well, actually sometimes I do get headaches or yeah,
my sleep hasn't been great, and so then that will
create a separate diagnosis and you know, discussion and treatment
plan and maybe physical exams. So then they have the
components to charge you for a separate visit. So it

(17:48):
is not uncommon. You know, we hear this all the
time from patients that come to our practice that were
previously seen in the fee for service insurance world that
you know, well, I went into my doctor for my
once a year and they said insurance that you know,
that should be covered. I should not have to pay
for that. But then they sent me a separate bill
saying because I mentioned this one issue that I was having,

(18:09):
because the doctor asked me about the issue, now they
build me a separate visit for that. And it's super frustrating.
And again it almost discourages people from telling stuff to
their doctor, as you mentioned, Sean, and it almost discourages
people from going to the doctor, even though the whole
purpose of the the ACA requirements of the preventive care

(18:30):
visit was that it would it would get more people
to go into their doctor once a year. So it's
it's ironic that it has kind of morphed into this
and and this always happens because health insurance systems, hospital
systems will find newing, creative ways to build people.

Speaker 3 (18:43):
That's it. Yeah, you know, that's that's kind of how
they exist and grow.

Speaker 1 (18:47):
You know, as we talk about this stuff too with
doctor Nicole Hempkis of Advocate MD, there's a better there's
a better way, especially when it comes to primary care,
and of course is direct primary care with the Advocate
MD and doctor. One of the things people do wonder
about that and it's like, well, Okay, I'm paying for insurance,
but Advocate MD doesn't charge insurance. Isn't that kind of
a duplication and those type of things. What I love

(19:09):
seeing is is we talk about kind of crunching the
numbers and looking at the looking at the numbers, you
can act it's actually not only are you getting better
primary care service and of course care you have access
if gosh forbid, you do ever need. With that high deductile,
you've got access to that coverage and then you look,
you're saving money at the same time. It's pretty amazing

(19:29):
what you're able to do. And I sometimes wonder, is
are there some people that just think this is just
too good to be true?

Speaker 2 (19:38):
Yes, I definitely think that that is possible. You know,
I think as we've been around longer now, the practice
has been around longer, and people kind of see and
hear things more and maybe see commercials or you know,
the bus ads, or they have friends or family that
have have come to see us. Then it gets some
you know, there's more legitimacy and it's more familiar to them.

(19:58):
But if people ever have questions or you know, we
do offer potential patients the option to come in and
do like a fifteen to twenty minute meet and greet.

Speaker 3 (20:07):
With the doctor.

Speaker 2 (20:08):
Again, for our regular existing patients, they get an hour
with the doctor, but this is for people that are
not existing patients that just kind of want to maybe
come in and see one of the clinics, meet with
one of the doctors that they potentially would be they're
patient of that doctor, and ask general questions about the practice.
You can always go into the website through the contact

(20:29):
us and those emails come to me personally. So those
are more to ask questions about the practice or if
you had a specific you know, health issue or whatever.
Is this something that you guys can take care of?
Is this something that you guys can help me with?
Or would this be outside your scope? Those kind of
questions are fine too. But yes, you're right, Sehan. I
think sometimes people think this does sound too good to

(20:51):
be true for the sixty or eighty dollars a month,
and you know, how are your price is not higher?
And of course you know we can keep our overhead
life because we don't have to involve insurance.

Speaker 1 (21:02):
It's an amazing model. It's it's so many great benefits.
And folks that have been listening to the program for
some time, you know all the great benefits that come
along with Advocate MD. Make sure you're telling your friends
and family as well. Over this. Over this, I say holiday,
I guess you have Follow's day. Counsel is on holiday.
At least in my book, I'm going with it big time. Holiday.
We can talk with the folks, you see, let them

(21:22):
know about Advocate MD. If you haven't made an appointment
you have become a member. Today's day to do just that.
Pick up phone, give me a call six oh eight
two six eight sixty two eleven. That's six oh eight
two six eight sixty two eleven. Of course you can
learn more online the website Advocates DPC dot com. That's
Advocates DPC dot com. Doctor Hamkiss, it's always great chatting
with you. We have a fantastic weekend and we'll talk.

Speaker 2 (21:43):
Real soon you too, Sean, Thank you.

Speaker 1 (21:45):
News comes your way next right here on thirteen ten.
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