Mar 10

Facts about Insurance

Facts About Insurance

As a medical practice, we strongly believe our patients deserve the best possible medical care we can provide. In an effort to maintain a high quality of care, we would like to share some facts about medical insurance with you.

Fact #1: Your medical insurance is based upon a contract between you and your insurance company. Sometimes this also involves contracts with an employer and you or family member. Should questions arise about your medical insurance benefits, it is best for you to contact your insurance company directly or your employer.

Fact #2: Medical insurance benefits differ greatly from company to company. Your premiums, co-payments, co-insurance or deductibles may change or increase without notification to you. Your allowed benefits may be different from one visit to the next. We will do our best to collect the correct amount on the date of service. However, we may not know the full amount owed until your insurance pays the claim.

Fact #3:
You may receive notification from your insurance company, stating that the medical fees that we billed are higher than usual and customary. An insurance company surveys a geographic area, calculates an average fee, takes a percentage of that fee and considers it customary. The fee for service doctor in private practice will have fees that insurance companies define as higher than usual and customary. There may be contractual discounts applied in most cases. The patient is not responsible for the contractual adjustment, only co-payments, co-insurance, deductibles and services not covered by your insurance plan.

Fact #4: Many plans tell their participants that they will be covered up to a certain amount but do not clearly specify plan fee schedule allowances, annual maximums, limitations or covered benefits. Again, the final amount owed by the patient comes along with the insurance company payment and is called an “explanation of benefits” or an “EOB”. Once the EOB is received we will then know the final amount owed for each date of service and in some cases for each injection. Depending on how prompt your insurance company processes your claim, this can take up to a couple of months.

Fact #5: Routine or well child services are covered by most of the insurance companies. Immunizations are billed and sometime paid separately. Although an insurance company may pay for the well check, immunizations may not be covered. Please varify your benefits from your Health Plan. My staff will be able to help you undestand the benefits.

Financial arrangement must be made directly with us, regardless of insurance coverage. Please do not hesitate to ask us. Thanks,
Suresh Sachdeva, MD