How are direct pays handled compared to reimbursement claims?

Nearly all claims in Latin America are out of pocket.

One major difference with health coverage through international insurers is that you will almost always pay 100% out of pocket for medical visits or procedures in Mexico and other Latin American countries. This is because claims are generally minor, costs are low, and will only rarely exceed your deductible. You will then file your claim to go towards your deductible, or for reimbursement.

There are times when the insurer will arrange a direct payment to the doctor and/or hospital. If you are in an emergency accident that requires 24 hours or more of hospitalization, or if you have a planned surgery, the insurer will contact the facility to see about issuing a Guarantee of Payment (GOP) letter. The doctor and/or hospital has the option to accept this GOP in lieu of payment from the client. Please keep in mind that the doctor or hospital are under no obligation to accept a GOP from any insurer and may  still request the client to pay directly. In this case, you can either find another facility that will accept the GOP, or pay the doctor or hospital out of pocket and then file a claim for reimbursement.

Once the GOP is accepted, you will be responsible for paying any remainder of your deductible, as well as a copay if applicable. This information will be listed on the GOP and these payments will be made directly to the doctor/hospital. Another cost to expect when checking into the hospital is a deposit to start treatment. It is typically $20,000 pesos (about $1,000 USD), but that number can vary. Again, this is something done by the hospital regardless of the GOP or your deductible. You will need to keep a record of this payment (receipt) and file that claim as well to be reimbursed.

We strongly recommend that you precertify any surgeries you have planned to either have the payment handled between the insurer and hospital, or to at least have the procedure approved by the insurer beforehand to avoid any unwelcome surprises. We go over the complete precertification process in this article.

Please contact your broker if you have any questions about direct pay and reimbursement.