Insurance Policies and Issues

One of our realities is dealing with insurance companies. Understanding insurance rules can be confusing. We participate with many insurance programs and each has its own rules and requirements. Four aspects of those rules are:

In our practice, health insurance DOES NOT influence medical decisions… however, health insurance DOES influence services.

1. Restrictions on Services

For example, there may restrictions on which laboratory facility can be used, which specialists may be consulted or which medication formulary to use. Some plans, such as PCP, require that the patient secures written referral to consult a specialist, and this must be obtained BEFORE the consultation. This is often called the hassle factor, and some plans provide more hassles than others do. These restrictions can be dealt with, but you must know your health plan’s rules and procedures before you need care and follow them when you do.

2. Non-covered Services

Insurance will pay for many of your health care expenses, BUT NOT ALL OF THEM. Some services may not be covered by your policy and they will be listed as exclusions in your policy manual. Examples include PSA testing, weight control management, etc.

Also insurance companies sometimes reject some services we may provide as “not medically necessary”. Their decisions are arbitrary and bureaucratic, not medical, and we cannot take any responsibility for those determinations. In such cases, you are responsible for the payment in full. Nonetheless, we recommend that you take it up with your carrier and request then to reprocess your claim.

3. Payment for Services

Another aspect of managed health care is payment for services rendered. We consider ours a fee-for-services practice, even while we participate with many insurances. Our patients are ultimately responsible for charges incurred at the office, laboratory or hospital. We request payment at the time of your visit for that portion of the fee for which you are always responsible (e.g. co-pays, deductibles, or the entire fee), depending on your insurance.

It is your duty to know how much deductible you are currently responsible for. Please present your last EOB (Explanation of Benefits) to the staff prior to your treatment. If you don’t, you must pay a deposit at the time of service.

4. Billing and Collecting Policies

To receive payment for claims, the insured have to fill out forms and send them to their insurer. Some doctors’ office will do this for their patients. However, the filing of claims is increasingly more bureaucratic and expensive. Insurance companies like it when doctors’ offices file claims for patients because they have fewer individuals/entities to deal with Patients like it because it is convenient for them. Our office does file claims and we offer it STRICTLY as a courtesy to our patients. We consider it a value-added service and not our responsibility. We do reserve the right to charge for this value.

If you prefer us to file your claims, we forward them to your insurance and after a few weeks we should receive an Explanation of Benefits (EOB) back from the insurance company. After we process the EOB, we mail out “Patient Statement” if the amount you had paid us at the time of service was insufficient to cover the visit. Payment is always due on receipt. If, on the other hand, you overpaid us, we will issue you a refund check.

If we have not heard from your insurance company within approximately 6 weeks from the date of your visit, we will also send you a Patient Statement for that visit. It will show that payment responsibility has been transferred from the insurance to you. At this point, you are responsible for the payment and may request reimbursement from your insurance company.

In our practice WE DO NOT send monthly billing reminders. If we have to refill you, we will apply appropriate billing charges to your statement, which is the last statement you will receive before placing your account in collection.

All self-paying patients are guaranteed a discount at the time of service.

To discuss any of the these issues please call the office at 228-875-1599.

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