Coinsurance Amount

Coinsurance amount applied to patient responsibility. The payer paid their percentage; the patient owes the remaining share per plan design.

What This Means in Behavioral Health

After deductible is met, BH program per diem often splits via coinsurance—20% patient / 80% plan is common on commercial policies. PR-2 on institutional claims affects patient collections and cash flow forecasting for treatment centers.

Root Causes

• Coinsurance percentage applied per contract after allowed amount determined
• Out-of-network coinsurance higher than in-network (e.g., 40% vs 20%)
• Copay vs coinsurance misquoted at admission
• Secondary payer did not pick up remaining coinsurance when expected

Prevention Tips

• Document coinsurance and OON benefit tiers in VOB before admit
• Bill secondary promptly when coordination applies to coinsurance
• Train admissions on difference between copay, coinsurance, and deductible for BH benefits
• Reconcile patient statements to PR-2 on ERA weekly