UNDERSTANDING BILLING AND INSURANCE
To receive the fullest coverage you first need to understand how billing and insurance work. The best place to start is with your medical insurance. You should make a call to your insurance before you schedule your exam. Here are some topics about billing and coverage you should discuss with them.
- Does Dr. Affleck participate in your insurance plan?
- What are the amounts of co-payment, co-insurance, and deductible?
- Are there non-covered services?
- Are there referrals, pre-authorizations or other documentation needed before visiting with Dr. Affleck?
- Do you have medical eye coverage and vision eye coverage?
We accept most major medical insurance. However, learning about and discussing coverage with your insurance will help you have a smooth billing and payment experience.
As a courtesy to you, we will submit a claim to your medical insurance. However, as part of the treatment agreement you (the insured/guardian/patient) are responsible for knowing about the coverage and billing of your insurance policy. You are to facilitate payment of claims and dispute any denials. This means, you are to ensure your insurance company pays. You will also be responsible for satisfying any conditions necessary for insurance or health benefits, not Affleck, MD Eye Care.
WHAT IS DUE AT THE TIME OF YOUR APPOINTMENT?
Each patient (who wants to use their insurance) must provide an insurance card. This requirement comes from your insurance and is non-negotiable . We will not be able to submit a claim without a copy of the card on file. If you do not present a current card at each visit we may need to collect full payment of the services at check-in.
A patient’s full payments are due at the time of the appointment. For instance, we will collect your portion of the charges (copay, deductibles, co-insurance, and non-covered service fees) before seeing the doctor. Additional bills may be sent to the patient once the insurance has determined the patient’s portion.
VISION INSURANCE
Most vision insurances are discount programs. We do not participate in vision discount plans. Vision plans are added “coverage” to a medical plan or a standalone plan. These plans usually only cover products like glasses and contact lenses. They also will normally only pay for a refraction test, and a preventive screening exam. These preventive screenings are also known as a routine eye exam. To learn more about how to use your vision insurance while seeing Dr. Affleck, Click Here.
HEALTH CARE PRICE TRANSPARENCY
Like most medical practices, Affleck M.D. Eye Care is a passive participant of the cost of healthcare services. The reason for this is that insurance companies determine the cost of a service instead of the fair market price system. If you look at your explanation of benefits documents you may see the word “Allowable.” This is a nickname for the insurance companies setting the fee or price of the service. It is what allows a provider to be paid. A list of these prices for services is called a fee schedule.
HEALTH CARE FEE SCHEDULES
Each patient’s fee schedule varies dramatically. Factors like who is paying, the location of the service, the specific plan, and so forth determine the price of a service. It is rare for physicians to have easy access to these fee schedules. Therefore, understand your out-of-pocket-cost must BEGIN WITH A CALL TO YOUR MEDICAL INSURANCE COMPANY.
ANTICIPATING THE COST OF HEALTHCARE SERVICES
At Affleck M.D. Eye Care we encourage patients to seek information regarding the anticipated cost of health care services directly from their insurance company. This is the most reliable resource. Unfortunately, in most cases we are not provided this information until after the service is performed, and billed.
Do You Know About An Allowable?
An Allowable is the term used to describe an insurance set price.
Medical insurance companies set the pricing of services. They are called the allowable. Your doctor will discount the price to match the allowable amount. Many times it is difficult for your doctor to know those pricing before a claim is determined. When you want to understand your cost of services only your insurance will have this information.
Do You Know About Medical Necessity?
Medical necessity is not the same as a medical benefit.
Your insurance determines coverage for services. This is called a medical benefit. Your doctor determines the medical care you will need. This is called a medical necessity. If your insurance declares your medical care as NOT medical Necessity it will not cover the charges.
FINDING A GOOD FAITH ESTIMATE
- Cataract Surgery, Medicaid 2021
- Cataract Surgery, Private Insurance
- Cataract Surgery, Self Pay
- Eye Alignment (muscle) surgery, Child – Coming Soon
- Eye Exam, Medical Reasons, Self Pay
- Laser assisted – DCR surgery, Adult – Coming Soon
- Plugged Tear duct, child at office – Coming Soon
- Plugged Tear duct, child at office – Coming Soon
IMPORTANT TERMS
A term used for a mandatory discounting the amount billed for a medical service in accordance with the contract between Affleck M.D. Eye Care and an insurance company.
The payment a participating provider agrees to accept for a service. The approved amount is decided by insurance company fee schedules.
An arrangement where patients and their insurance company share payment of a health care service. Coinsurance takes effect after the deductible amount has been paid. The coinsurance usually is a percentage of the cost of medical services after the deductible is paid until the annual maximum out-of-pocket expense is reached.
Example: A patient has a $500 deductible and a 20 percent coinsurance with an annual maximum out-of-pocket amount of $5,000. This patient must pay $500 with his/her own money before the insurance company starts to pay. When the insurance company does pay, it will pay 80 percent of the approved amount.
The patient pays the remaining 20 percent with his/her own money. The patient will keep paying at 20 percent until he/she spends $5,000 of his/her own money and reaches the annual maximum out-of-pocket amount. At this point, the insurance will pay 100 percent of the approved amount.
The difference between what an insurance company approves according to its contract and what the health care provider charges for the procedure. If the provider is under contract to accept the patient’s insurance plan, the patient is generally not responsible for this difference. A contractual allowance shows up on a billing statement as an adjustment required and decreases the balance.
Current Procedural Terminology codes, also known as CPT® codes, constitute a set of five-digit codes used to describe the medical, surgical, and diagnostic services done. CPT codes allow physicians, patients, counsel, insurance companies, and others to communicate effectively throughout the United States.
The minimum amount of money patients must pay before their insurance company pays any health care expenses. Usually, the deductible needs to be met and paid by patients each year.
An Explanation of Benefits is a document provided by the insurance company that tells how a claim was processed. It also explains why a claim was or was not paid, and what portion the patient is responsible for. Other terms that mean the same thing are EOP (Explanation of Payment), EOMB (Explanation of Medicaid Benefits), and MSN (Medicare Summary Notice).
A listing of the maximum amounts that a health insurance plan will pay for certain services. A fee schedule is based on CPT® codes.
Refers to the person responsible for receiving and paying the bill for medical services. The guarantor may or may not be the patient. A parent or legal guardian/trustee is the guarantor for patients 18 years old and under. This is also the case for patients with a decreased mental capacity.
Refers to the person responsible for receiving and paying the bill for medical services. The guarantor may or may not be the patient. A parent or legal guardian/trustee is the guarantor for patients 18 years old and under. This is also the case for patients with a decreased mental capacity.
The maximum out-of-pocket expense is the total coinsurance amount that patients must pay before the insurance pays at 100 percent. Most insurance plans set up a yearly maximum out-of-pocket limit ranging from $1,000 to $5,000.
Some plans may have even higher MAX-OOP. When a patient reaches the set limit through coinsurance, deductible, and copayments, the insurance company pays the remaining bills at 100 percent until the new benefit year begins
Relates to procedures, treatments, supplies, devices, equipment, facilities, or drugs that are needed to diagnose or treat a medical condition. To be medically necessary, the services must meet the standards of good medical practice in the local area.
In addition, services cannot be mainly for the convenience of the patient or the doctor. Many insurance companies pay only for “medically necessary” services. This means that routine physical exams, cosmetic surgery, or preventive care may not be covered.
A service, test, supply, or procedure that is not a benefit in a patient’s health insurance policy. Patients are responsible for paying for all noncovered services. The insurance company can give the details of what test, procedure, or service is not covered.
When a physician or facility does not accept a patient’s health insurance plan. When the patient receives services from a nonparticipating physician or facility, the patient is billed directly for services and is responsible for payment in full.
Services delivered by a physician or facility that does not have a contract with the patient’s insurance company. Typically, managed care plans contract with a panel of providers (group of facilities and physicians). When patients seek care from a physician or facility that is not in the panel, they are getting care out-of-network.
The patient may be responsible for some or all of the costs for out-of-network care. Emergency medical care usually is an exception to the OON rule.
Expenses paid by patients.
A term used when a physician agrees to accept an insurance company’s approved amount as payment in full. In this case, the bill for services is sent directly to the insurance company and payment is made directly to the physician.
The insurance payment for physician participation excludes amounts considered to be a patient’s obligation under the patient’s insurance plan. That means coinsurance, deductibles, and noncovered services have to be paid by the patient.
An insurance plan that contracts with independent providers at a discount for services. The discounts can be 10 percent to 40 percent below normal fee schedules. Typically, the panel of providers (the participating physicians) is limited. There is usually some type of utilization review system associated with a PPO. Patients can use a physician outside the PPO panel of providers, but they will have to pay a bigger portion of the fee
Refers to any supplier of health care services. Providers can be physicians, pharmacists, physician assistants, physical therapists, or nurse practitioners. Providers can also be places such as hospitals, ambulatory surgery centers, skilled nursing facilities, or home health agencies.
A term used for the insurance company that has first responsibility for payment of a claim.
The first doctor who patients see for an illness or health care need. The primary care physician treats patients directly. The PCP also sends patients to a specialist (secondary care) and admits patients to a hospital. PCPs may practice family medicine, internal medicine, pediatrics, or sometimes obstetrics/gynecology
A physician’s medical order for services or consultations to be provided by another health care provider such as a specialist. Some insurance companies require written approval or consent from a primary care physician (PCP) before a patient can see a certain specialist or receive certain services. These insurance companies may not pay for the specialist’s care without first getting an “insurance” referral from the PCP.
Defined as the insurance company that has responsibility for payment after the primary insurance pays or rejects an insurance claim.
The person responsible for payment of premiums, or whose employment is the basis for eligibility for a health plan membership.
Describes the preset allowable limits insurance companies use to set the maximum amount they will pay on a given health care service. A common way to set UCR fees is to get a list of existing fees for an area, average them, and choose an amount higher than average, but not 100 percent. UCR is used instead of the term “Fee Schedule” when a provider is not contracted with the health care plan.