At Inner Peace Medical Billing, we believe in taking the stress out of healthcare billing. Below are some common questions patients have—answered simply and clearly—so you can feel informed, prepared, and at peace.

What is “medical necessity”?

Medical necessity means the service or procedure is considered essential for diagnosing, treating, or preventing a health issue. Your insurance will only cover services they consider medically necessary. If a service isn’t deemed necessary by the insurer, they may deny payment—even if your provider recommends it.

What is an out-of-pocket maximum?

This is the most you’ll have to pay in a plan year for covered services. Once you've reached your out-of-pocket maximum, your insurance pays 100% of the allowed amount for covered services for the rest of the year. It includes your deductible, copays, and coinsurance—but not your monthly premium.

What does “patient responsibility” mean?

Patient responsibility is the portion of the bill you are expected to pay, which can include your deductible, copays, coinsurance, or services not covered by your plan. We will always bill your insurance first (if applicable), and once they process the claim, we’ll send you a statement for any remaining amount.

What is a copay?

A copay (or copayment) is a fixed amount you pay at the time of service. For example, you may have a $20 copay for a doctor’s visit. Copays usually don’t count toward your deductible, but they do count toward your out-of-pocket maximum.

What if I have more than one insurance plan? Which one is billed first?

When you have multiple plans, insurance companies follow a set of coordination of benefits (COB) rules to determine which plan is primary. Here’s a basic guide:

-Your own plan is usually primary over a spouse’s.

-For children, the "birthday rule" often applies: the parent whose birthday comes first in the calendar year typically has the primary plan.

-Medicare and employer plans: Usually, employer coverage is primary, and Medicare is secondary (in most cases).

If you're unsure, we’re happy to help clarify your coverage and make sure claims are submitted in the correct order.

What is coinsurance?

Coinsurance is your share of the cost for a covered service, calculated as a percentage. If your plan has 80/20 coverage, your insurance pays 80% and you pay 20% of the allowed amount after your deductible is met.

Still Have Questions?

We know insurance can be overwhelming—but it doesn't have to be. If you need help understanding your statement or coverage, please don’t hesitate to reach out.

Compass@innerpeacemedicalbilling.com