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
Your Primary Insurance covers your medical expenses up to a certain amount. You may also have insurance through a parent, spouse, voluntary or supplement which is considered your secondary insurance. It is your responsibility to know what insurance plans you have and provide all information up front before your visit.
Network
In-Network means a facility, provider, or medical practice contracted with your health insurance to provide services. Contact your insurance carrier to assure we are in-network.
If a provider is “out-of-network” you may be responsible for a part or all of the charge.
Co-Pay
This is a fixed dollar amount you will pay for some covered services. This is due up front at the office before your appointment. Please contact your insurance carrier if you have questions about your co-pay.
Example: $20 co-pay for doctor’s visits
Co-Insurance
Co-Insurance is your cost share after insurance pays and may be after your deductible depending on your specific plan. Please contact your insurance carrier with questions.
Example: 80/20 – means your insurance will pay 80% of the visit and you will owe 20% of the allowable.
What and When You Pay
This can vary depending on your insurance plan, here are some common examples of what & when you may be asked to pay.
Deductible
The amount you have to pay upfront before your insurance kicks in and help cover costs
Out-of-Pocket Max
This is the most you will pay in a policy period (usually one calendar year) for care before your insurance will cover costs at 100%. (Co-pays may still apply)
Referrals
Some insurance carriers require a referral for care outside of your primary care. Please contact your primary care or your carrier if you have questions. Our office will not be able to assist you with this.
Prior Authorizations
Sometimes services you need such as imaging, procedures, medications, and surgeries require approval by your insurance carrier before we know if that service is covered. If required, we will submit on your behalf.
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 do you pay these fees?
These estimates are expected to be paid upfront with the office before your visit. If there are balances after your insurance considers your charges you will be sent an electronic statement. Please make sure that we have your current email, phone number, credit card and billing information on file.
Payment is due within 30 days of the statement unless prior arrangements are made with billing.
OB and Surgery Estimates
Our office policy is pre-payment of all estimates prior to care (OB & Surgery) unless prior arrangements have been made with billing.