Insurance Coverage, Fees, and Payment Policies
Understanding Your Coverage
We understand insurance can be complicated and we want to help you understand your basics. Here are some key terms you will see that you need to understand before you come to a doctor’s office.
Health insurance is complicated and it can be hard to choose a plan so it is important to understand the basic elements in an insurance plan.
Health insurance is a policy that covers a percentage of medical care but often does not cover all expenses. It exists to help offset the costs of unexpected and expected costs of medical events when they occur.
Questions?If you have questions about your health insurance it is important to call your insurance carrier directly. Our office is unable to answer policies or coverages set by your plan.
Primary insurance vs Secondary Insurance
Primary Insurance is your main insurance plan that covers your medical expenses up to a certain amount. You may have additional insurance through a spouse, employer, voluntary or supplemental coverage that gives additional coverage. It is your responsibility to know what insurance plans you have and provide these up front before your visit. If they are not provided you will receive a bill for services performed.
Network
In-Networkmeans a facility, provider, or medical practice are contracted with your health insurance to provide services. Contact your insurance provider to confirm if someone or someplace is “in-network.”
If a provider is “out-of-network” then you may pay more to see this provider.
Co-Pay
This is a fixed dollar amount you will pay for some covered services. This is due upfront at the office before you are seen. Please contact your insurance provider if you have questions about your co-pay amount.
Example: $20 co-pay for doctor’s visits
Co-Insurance
After you reach your deductible amount, this is how much you will pay for each visit.
Example: 80/20 – means your insurance will pay 80% of the visit and you will owe 20% of the visit
What and When You Pay
This can vary depending on your insurance plan, here are some common examples of what you may be asked to pay and when you will be asked to pay.
Deductible
The amount you have to pay upfront before your insurance will kick in and help cover costs.
Out-of-Pocket Max
This is the most you will pay in a policy period (usually 1 calendar year) for care before your insurance will cover costs at 100%.
This limit includes deductibles, coinsurances, copayments or similar charges required for qualified medical expenses.
Prior Authorizations
Sometimes services you need such as imaging, procedures, medications, and surgeries require approval with your insurance company before we will know if that service is covered.
Who sets these fees?
Your insurance provider sets all of these fees. Our office must comply with the fees your insurance provider have set.
When are these fees owed?
The fees are expected to be paid upfront with the office before your visit. Any fees owed after the visit will be sent via a patient statement to you.