What’s going on with this bill?

by Alison P.

Have you ever looked at your medical bill and thought to yourself ‘someone failed math class?’ What your doctor bills and what they are paid is dramatically different. Nothing seems to add up correctly.

So what exactly happens after you leave the doctor’s office? Let’s take a look at an example and see if we can help you understand it.

Sarah goes to her in-network doctor on Feb 2 for an office visit and receives an X-Ray. After she leaves, her doctor sends a claim (bill) to her health plan for payment. Sarah’s insurance company then calculates how much they will pay and how much Sarah will pay for the services.

Claim for Sarah:

For Sarah’s visit on Feb 1, the doctor billed three separate items for one visit: office visit, medical services, and X-Ray. The Amount billed column shows what Sarah’s doctor is billing for each service. The insurance company reviews their contract with the doctor to determine what they agreed to pay the doctor for each service, this amount can be found in the Member rate column. Sarah’s insurance plan decides that the $25 fee for medical services is not something they agreed to cover; this amount is shown in the Pending/not payable column- neither Sarah nor the insurance will be responsible for paying this amount. Sarah’s copay for an office visit is $20, and is listed in the Copay column. The Amount Remaining is calculated by subtracting the copay amount from the member rate. The Plan pays column shows what the insurance will pay the doctor for services.

From this example, we can see that:

  • the doctor billed $225.00.
  • the doctor will receive $20 from Sarah.
  • the doctor will receive $85 from Sarah's insurance company.
  • the doctor will then zero out the remaining balance of $120.

One question you may be asking yourself is, “why doesn’t the doctor just bill the amount my insurance company is willing to pay?” Good question! Because there are so many different plans and negotiated fees for services, the doctor will bill high to guarantee they receive the full amount agreed upon from your insurance company. Remember, not all plans are created equally. Sarah’s plan is willing to pay $80 for an office visit, but your plan is willing to pay $95 for a visit. If the doctor only billed $80 for your office visit, they would lose out on an extra $15 they could have received from your plan. The doctor and the insurance provider are playing a negotiation game with every bill. If you didn’t have insurance, you would be responsible for paying the doctor the full amount of $225.

From this example we can see it definitely pays to have insurance. But which plan is right for you and what will you actually have to pay for doctors visits and care that you know you'll need?

At Take Command Health, we have lots of actual data from medical claims to help you estimate what your costs will be for the next year. While insurance companies keep their contracted rates close to the vest, we do our best to equip you to be a savvy health insurance consumer. To get started and see which plan will actually cost you the least, visit


Picture of Alison P.

Hi, I'm Alison P.! I graduated from Miami University, in Oxford Ohio, with a degree in Public Administration. I am passionate about simplifying health insurance for consumers and employers who wish to provide benefits for their employees. When I'm not writing you can find me practicing yoga and fantasizing about travel.