FAQ on Insurance Billing and Lab Coverage August 2016
Currently, there are over 35 major companies in our health insurance landscape. Each one of these 35 companies’ offer hundreds of plans. To add insult to injury, every one of these plans is different. While we work very hard to try to understand the most popular plans of our patients, it is impossible to understand everyone’s individual plan. However, we are medical providers and not insurance agents. We do not have any additional “power” with your insurance company, in reality, you- the patient; the policyholder has much more say in what is covered than we do.
We simply use the labs we do based on what we deem is important data that we need to treat you properly. We do not take in consideration the 100’s of insurance plans when we look at a new test. We look at the test to see if it will give us information to assist in treating and diagnosing the patient.
As patients, it is your responsibility to find out what your insurance covers in regards to labs and procedures that we order. Starting August 1, 2016 we will not be assisting you with your medical bills or lab bills unless it is ordered from the lab itself. If there is a coding issue, please know the lab and/or insurance company will contact us directly. They mail us information, they fax us. We give them the updated information if they ask. When it gets to you, please know that we have already done our part and done all we can do. If you have a plan that won’t cover a certain test, there is no way for us to make them change their mind. By doing this, we can focus on what we are truly here for, patient health.
Below is a list of frequently asked questions to assist you in this transition:
Q. The Doctor told me a certain test was a certain amount and now I am getting a bill. He said it would be covered. Why is this happening?
A. The Doctor is not an insurance agent, they are Doctors. They are ordering this test because they believe that it is beneficial to your treatment. Many tests follow the same rules and they were simply explaining to you that there was a cost involved. It is still your responsibility to talk to the lab and/or read the inserts included with the test to find out your responsibility. Phone numbers and websites for the lab are listed under the Insurance and Policy tab of our website.
Q. I received a bill for blood work because it wasn’t coded correctly. Can you recode this for me?
A. If you are getting a statement from the lab stating you owe them money for what you believe is a coding issue, please know that the lab usually contacts us prior to sending you a bill. If there is a recode necessary, we will recode only what is in your chart. We will not state that you have a certain condition or disease just to get your test covered. That is considered Health Care Fraud and we won’t do it. Please don’t ask us as it puts the doctor and staff in a compromising position.
Q. I have Medicare so why am I getting a bill from your office?
A. This question can be answered one of two ways. The first is that in the beginning of every year, all RED/WHITE/BLUE Medicare patients have a deductible they have to pay to their doctors. The patient sees the doctor and the doctor bills for services. Once Medicare receives the claim, they send to the doctor an allowed amount that the patient is to pay the doctor. This will happen to you until you meet the $166.00 Medicare deductible. Once that is met, they pay 80 percent and you are responsible for the 20% in either the form of self pay or a supplemental plan. We cannot write this off, as it is illegal to do so. If you have any questions, our billing department is always available to help you. The other option is that we have not received your secondary insurance or there was an issue getting the claim to your secondary. Please call the billing office and we will straighten it out for you.
Q. I have Medicare through AARP, The Villages, Humana, Aetna etc. Why am I getting billed?
A. In the medical world, Medicare is considered the RED/WHITE/Blue card with a supplement. Those AARP, Villages, Humana “Medicare” plans are called Medicare Advantage plans and operate quite differently than Medicare. Usually there is a much larger out of pocket cost. We only bill you what the insurance company tells us to. These types of questions should be brought up to your insurance company and they will make contact with us if any clarification is needed on their end.
Q. I paid a copay for therapy and now my insurance company is telling me I overpaid and nned a refund. How do I receive this?
A. Every month that you have a claim in our system, our computers print out a report of refunds and overpayments. Once we know it is a true overpayment, a check is cut to you within two weeks of that report. Some patients choose to leave it there and not pay additional copay which is permissible. Transferring the overpayment to the vitamin shop is not permissible and that request will be denied.
Q. I know I have a deductible and don’t like getting bills, can I just pay you now?
A. Unfortunately, it is illegal under our Medicare contract to do this. If you happen to get your EOB before you receive a bill from us you are free to come in and pay it. Otherwise, we ill bill you.
Q. I called the lab and my insurance won’t cover a test and I simply can’t afford it.
A. We understand. We do. Please just let us know this information and we will attempt to find alternatives to get the information we need that is beneficial to your case.
Q. I went to the lab and/or started a test and they are asking for an ABN, what is it and why do I have to sign it? What happens if I don’t?
A. An ABN is an Advanced Beneficiary Notice. It means that we as a physicians office understand that sometimes you have hit certain caps on your policy or that certain tests are allowed after certain conditions are met. By signing that ABN, you are signing that you understand there is a possibility you may be billed for the test. It does not mean it’s not covered, it also does not mean it is covered. It means that Medicare is reserving the right to not pay and you understand this. If you sign this and they cover the test, nothing happens. If you sign this, do the test and Medicare denies all or partial of the test you will receive a bill from us or the lab.
Q. I don’t know what my copay is, do you? What happens next?
A. We have a computer system that let us know what the copays are for the major payors: BC/BS, UHC, Medicare and Cigna. Therapy copays are not listed on this site. We do the best we can to help you in this manner. In some cases we will give you the codes to find out from your insurance company so you know ahead of time.
Q. I have been to PT this year and think I used up all my visits. Now what?
A. If you tell us that you have had therapy before, we run your account to find out where you stand. We then contact you and discuss options. This is done on a case by case basis.