Patient responsibility
Patient responsibility is the share of the allowed amount the plan assigns to the patient — deductible, copay, or coinsurance. It is set by the plan, not the provider.
Updated
Patient responsibility is the portion of the allowed amount a plan assigns to the member rather than paying itself. It takes three main forms: a deductible, the amount a member pays before the plan begins paying; a copay, a fixed amount for a service; and coinsurance, a percentage of the allowed amount.
It is a benefit design, not a provider decision. The plan determines what the patient owes when it adjudicates the claim, and the remittance reports it — which is why a patient asking why their bill is what it is has usually asked the wrong party.
In practice
The critical detail for billing is that patient responsibility is calculated on the allowed amount, not the billed charge. A patient with coinsurance owes a percentage of what the plan allowed, so the contract that reduced the charge also reduced the patient's share — which is the opposite of what most people assume when they see a large adjustment.
Getting this wrong has consequences beyond a wrong number. A balance billed to a patient that was actually a contractual adjustment is a balance they do not owe, and on a healthcare bill that is a compliance problem rather than a customer-service one.
Commonly confused with
- Contractual adjustment: A contractual adjustment is written off and never billed to anyone. Patient responsibility is billed to the patient. The remittance's group code is what tells them apart.
- Non-covered amount: A non-covered service falls outside the plan's benefits entirely. Whether the patient can be billed for it depends on the contract and on what they were told in advance — it is not automatically their responsibility.