Insurance Facts

Our office is pleased to accept your insurance assignment. We offer this service as a courtesy to patients. It must be clearly understood, however, that the “contract” is between the patient and the insurance company, the account thereby being the responsibility of the patient for any amount not paid by the insurance company.

1. Your insurance is a policy that you or your employer has purchased from an insurance company. Every policy is different and our experience is that the vast majority will cover your medical fees. We are a third party in this arrangement.



2. Many plans state that procedures are covered “at 50%, 80% or 100%”. Be aware that the benefits your plan pays are based on the insurance companies’ usual & customary fees. The benefits your plan pays are largely determined by how much your employer/union paid for the plan.



3. Insurance companies’ established “Usual and Customary” fee schedules may or may not have an accurate relationship to what usual and customary fees actually are for a given area. It has been our experience that some insurance companies tell their insured that “fees are above the usual customary fees” – rather than saying to them that “our benefits are low.” There are various methods and calculations by which the company established their usual and customary fees. Therefore, it is possible that different insurance companies will have different allowable fees for the same geographical area. Our fees may be within one company’s but not within another company’s “usual and customary” range. Remember, you only get back what your employer/union puts in, less the profits of the insurance company.



4. We require all of our patients to sign the “Advanced Beneficiary Notice” form (and other necessary assignment documents required by your insurance company). By doing so, the insurance company will make payment directly to our office. The patient will pay the co-payment (amount not covered by the insurance company) as agreed upon. For those patients with dual insurance, we will file the secondary insurance after receiving payment from the primary insurance.



5. Our office does NOT guarantee that the patient’s insurance company will pay. We will perform our routine insurance billing procedures upon verification of coverage. If for any reason the patient’s insurance claim is denied, the patient is then considered to be responsible for the full amount of the bill.

DEFINITIONS

Coinsurance.

The percentage of the lesser of: (a) rates established under this Agreement; or (b) Facility’s usual, customary and reasonable billed charges, which a Member is required to pay for Covered Services under a Plan.

Copayment.

A charge required under a Plan that must be paid by a Member at the time for the provision of Covered Services, or at such other time as determined by Facility.

Deductible.

An amount that a Member must pay for Covered Services during a specified coverage period in accordance with the Member’s Plan before benefits will be paid.