| Date | Specialist | Patient net | Lost wages | Allowed | Insurer pay |
|---|---|---|---|---|---|
| 2026-02-01 | Cardiology | USD 171.10 | USD 22.50 | USD 255.00 | USD 164.00 |
| 2026-01-18 | Dermatology | USD 104.80 | USD 0.00 | USD 140.00 | USD 92.00 |
| 2025-12-07 | Orthopedics | USD 262.90 | USD 48.00 | USD 410.00 | USD 272.00 |
- Provider charge = base fee + (duration ÷ 60) × hourly rate.
- Telehealth: provider charge × (1 − telehealth discount %).
- Medical subtotal = provider charge + add-ons (procedures, labs, imaging, facility, prescriptions, admin).
- Out-of-network: medical subtotal × multiplier.
- Surcharges: medical subtotal × (1 + surcharge %).
- Medical with taxes = medical subtotal + (tax % × medical subtotal).
- Allowed amount = medical with taxes × negotiated rate %.
- Deductible pay = min(deductible remaining, allowed).
- Coinsurance pay = (allowed − deductible pay) × coinsurance %.
- Patient medical = copay + deductible pay + coinsurance pay (optionally capped by out-of-pocket max).
- No insurance: patient medical = medical with taxes − cash discount.
- Non-medical = distance × cost/km + parking + childcare + misc.
- Lost wages = time off hours × hourly wage.
- Expected follow-up = probability × fee; same for second opinion.
- Buffered total = patient total × (1 + contingency %).
- Net after savings = buffered total − (eligible costs × tax savings %).
- Annual cost = net after savings × visits per year.
- Pick a specialist type and visit mode.
- Enter fees, duration, and medical add-ons.
- Add travel, childcare, and time-off costs.
- Enter insurance details or cash discount.
- Add follow-up and second opinion probabilities.
- Use buffer, savings, and annual options.
Cost drivers that change the estimate
The visit total is built from provider time, add-ons, and plan rules. A 30-minute visit at a 220 hourly rate adds 110 to the base fee. Add-ons like labs or imaging can exceed the provider portion in many specialties. Out-of-network multipliers and after-hours surcharges apply to the medical subtotal, so they scale every item under that subtotal. If you add 60 in labs and 40 in prescriptions, a 15% after-hours surcharge increases those items too. Use the visit mode option to see how a 10% telehealth discount changes only the provider portion, not add-ons.
Insurance fields and what they imply
With insurance enabled, the calculator prices the claim against an allowed amount. The allowed amount equals medical-with-taxes multiplied by the negotiated rate percentage. Deductible is applied first, then coinsurance is calculated on the remaining allowed balance. The insurer portion is the remainder after coinsurance, while copay is added to the patient’s medical share.
Travel, time-off, and real household impact
Non-medical costs capture distance multiplied by cost per kilometer plus parking, childcare, and misc. Lost wages adds time-off hours multiplied by hourly wage. These two categories often decide whether a visit feels affordable, especially for in-person care. Telehealth can reduce provider charges, but it does not eliminate medication or lab needs.
Expected follow-ups and scenario planning
Follow-up and second opinion are modeled as expected costs: probability times fee. For example, 15% of an 80 follow-up equals 12 expected cost. This approach allows realistic budgeting across uncertain care paths. You can also set visits per year to convert a single-visit estimate into an annual planning figure. When budgeting for a chronic condition, try 4 to 8 visits per year and compare buffered totals. If your plan has an out-of-pocket maximum, enter the remaining amount to cap patient medical exposure in the model.
Buffers, savings, and reporting
Contingency adds a percentage buffer to reduce surprise from extra codes or supplies. Tax savings can reduce eligible costs in a simplified way when accounts provide pre-tax spending. Exports include buffered totals and net-after-savings for audit trails. Use the conversion option to view totals in a second currency using your rate.
FAQs
Does this match my final bill?
No. It is a budgeting estimate. Final bills depend on billing codes, contracted rates, plan rules, and claim edits. Use it to compare scenarios and prepare a spending range.
What is the allowed amount?
It is the priced amount used for insurance sharing. The calculator estimates it as medical-with-taxes times negotiated rate percent. Deductible and coinsurance are applied to this allowed figure.
How should I set the out-of-network multiplier?
Use a conservative factor that reflects higher billed charges, often 1.1 to 1.6. If you have a prior bill, divide out-of-network medical subtotal by in-network subtotal to calibrate.
Why include lost wages?
Time away from work is a real economic cost. Adding it helps compare in-person versus telehealth and supports total household budgeting, especially when travel and waiting times are significant.
How do probability fields work?
They create expected cost. The calculator multiplies probability by the fee, so 20% of 150 becomes 30 expected. This helps budget for uncertain but common follow-up pathways.
Can I export multiple scenarios?
Yes. Change inputs, calculate, then export CSV or PDF each time. Use different filenames to track scenarios, such as in-network versus out-of-network or telehealth versus in-person.