Expense Navigator FAQs

Have questions about Expense Navigator, our out-of-pocket medical cost estimate tool?  Please review our list of frequently asked questions (FAQs).

What is the difference between an inpatient and an outpatient procedure?

Inpatient procedures require that the patient be admitted into the hospital for at least an overnight stay. An outpatient procedure can be performed at a hospital but the patient does not typically need to be admitted before or after the procedure is performed.

How do you determine the "average charge" of a procedure?

The average charge amount is calculated by adding the total hospital charges for all patients in the last 12 months who obtained a specific test/procedure (outpatient) or were assigned to a particular Diagnosis Related Group (inpatient). This total number is then divided by the number of patients in that same group. These averages are recalculated each quarter.

What is a co-payment?

A co-payment is the fixed amount of money paid by a health plan enrollee (beneficiary) at the time of service. For example, the enrollee may pay a $10 co-pay at every physician office visit, and $5 for each drug prescription filled. The health plan pays the remainder of the charge directly to the provider.

What is a deductible?

The amount of loss or expense that must be incurred by an insured or otherwise covered individual before an insurer will assume any liability for all or part of the remaining cost of covered services. Deductibles may be either fixed dollar amounts or the value of specified services (such as two days of hospital care or one physician visit). Deductibles are usually tied to some reference period over which they must incurred, for example, $100 per calendar year, benefit period, or spell of illness.

What does "maximum out-of-pocket" mean?

This amount is the annual maximum a beneficiary can expect to pay for covered services in a catastrophic situation. This is the true “insurance” that is part of the health plan. The maximum out-of-pocket expense includes the deductibles and co-insurance, but does not include office co-pays or employee contributions.

What is coinsurance?

Coinsurance is a cost sharing requirement under a health insurance policy. It provides that the insured party will assume a portion or percentage of the costs of covered services. The health insurance policy provides that the insurer will reimburse a specified percentage of all, or certain specified, covered medical expenses in excess of any deductible amounts payable by the insured. The insured is then liable for the remainder of the costs until his or her maximum liability is reached.

What is a CPT?

Current Procedural Terminology. CPT codes are five-digit codes recognized by all insurance companies, hospitals and physicians. Physicians and hospitals use the CPT code to indicate the type of care or procedure(s) used to treat you. Insurance companies and providers use the codes to identify the care provided, and then, along with a diagnosis, to determine payment and reimbursement claims.

What is a DRG?

Diagnosis Related Group. A DRG relates strictly to an inpatient hospital service and is used by Medicare and most insurance companies to further clarify the type of inpatient care you receive and, along with a diagnosis code and the length of the inpatient stay, to determine payment and reimbursement for individual claims.