The amount we bill to all insurance companies is referred to as our Usual and Customary Charges. This fee is the same for all insured patients. This amount is calculated based on the rates Medicare pays for services. The amount we bill your insurer DOES NOT determine the amount you will owe for a particular service. We have contracted with insurers we are in-network with to accept a specific amount they deem appropriate for the service. This is referred to as the contract allowable and this is the actual cost of the service. We are required by our contract with in-network insurances to write off the difference between what we billed and what they allowed. This is referred to as the network discount and is shown on your statement as the Insurance Adjustment. You receive a significant discount from our Usual and Customary Charges for choosing an in-network provider.
LabCorp are in-network with all insurance plans Western Wayne Medical accepts. Depending upon your insurance coverage you may receive a bill from LabCorp. Self-pay patients pay for their labs in full at the time of service and should not receive a bill from LabCorp. If you are a self-pay patient who is receiving a bill from LabCorp please leave a message with the Billing Department to get this resolved. For insured patients, please contact LabCorp at 1-800-845-6167 for questions about your bill.
Unfortunately, no. Appropriate and accurate medical claims are required by federal law, and it is considered fraudulent to change billing information solely to obtain reimbursement. We therefore cannot, for example, code sick visits as well visits to avoid out of pocket charges to you, the member. We must also bill for acute or chronic condition services when they are provided during a well exam.
This depends. We are able to re-file claims if they need to be re-filed to a new insurance or if they legally need an alteration in the coding. However, claims that are put towards deductibles, denied out for coordination of benefits, or pending for further information from the patient cannot be re-filed. If we re-filed these claims they will be denied as a duplicate by the insurance company as the insurance all ready has the claim in their system. In these cases the patient needs to call and ask their insurance company to reprocess the claim.
It is Western Wayne’s policy to have all services coded by our providers before the time of check out so that you can pay in full and not receive any bills for your service. Unfortunately, our audit process occasionally identifies services that were rendered but were not coded. In these rare cases, your account maybe adjusted after you leave the clinic and a patient statement will be forwarded for the remaining charges.
If you have a high deductible insurance plan, your contract with your insurer states the deductible must be met before the insurer will issue any payments for medical office visits on your behalf. This is similar to automotive or homeowner’s insurance deductibles. For example, if you have a $1,500 deductible on a high deductible insurance plan, you must pay that amount before expenses are covered by your insurance. In this example, each time you come to the doctor your visit will be put towards your deductible until you have paid $1,500 out of pocket. We do recommend that you contact your insurance company as they will be able to explain your specific plan in detail and how much of your deductible you have met to date. Even co-pay insurance policies may have a deductible that applies to specific services such as labs or diagnostic imaging. Your insurance company can advise you as to what services have a deductible and how much deductible you have remaining on your plan. In many cases, your insurance may have an associated Health Savings Account (HSA) to help you pay for deductibles, and your insurer or your employer can advise you as to how you can access the funds in this account.
We cannot make adjustments to fees after a claim is filed with your insurance. When you present your insurance card, and we are in-network with that insurance, we are required by our contract with the insurer to file a claim on your behalf. It is your right, under the HIPAA Omnibus Final Rule published in the Federal Register on January 25, 2013, to pay in full at the time of service and request that we do not file a claim with your insurer. In these cases, we will honor the self pay fee schedule. You must complete our service specific waiver form at each visit that you do not want billed to your insurance and pay in full at the time of service.
Most insurance plans do cover one preventive physical per year at 100% as required by the Affordable Care Act, however a preventive exam typically means that you are going into the appointment with no medical concerns or problems. Insurers will apply a co-pay or deductible for any services that are outside of preventive care such as counseling or treatment of acute or chronic illnesses, similar to the way they would process your claim had you presented specifically for an acute or chronic medical problem. For example, if you go to your physical and also want to discuss your low vitamin D, your diabetes, or your stuffy nose, this is considered a completely separate service that generates its own fees. We do recommend that you call your insurance company and speak to one of their representatives who can outline what is and isn’t considered preventive under your plan. Please refer to our Insurance Coverage of Physical Exams form signed before each physical. Please also refer to our Patient Policies page where we have outlined relevant information in red.
No, we are not saying that. Our providers are happy to discuss any concerns you may have at any time, but specifically for the yearly preventive exam, treatment of conditions outside of preventive medicine is considered a separate service by your insurer, and will incur separate co-pay/deductible/co-insurance charges. Covered preventive services include: Screenings for common or preventable diseases Complete physical examination, including pap smear testing for women Review of immunizations and administration of any CDC recommended vaccines Counseling on healthy living choices, normal development, and recommendations for proper diet and exercise. Diagnostic testing deemed appropriate by the United States Preventive Services Task Force (USPSTF). Examples include pap smear, colonoscopy, and mammogram. Again, we are happy to work with you to resolve any medical issue or concern, but you should be aware of how insurance coverage for acute or chronic condition management is different than the insurance coverage for preventive services that is mandated by the Affordable Care Act.
As part of the contract you have with your insurance, some plans require that the patient pay a set amount for each visit. This may or may not include any tests or procedures associated with the visit. Some plans require a co-pay for the office visit and then have a separate deductible or co-insurance for labs and/or procedures. Some insurance policies may also have a combination of deductibles, co-insurance, and co-pays. For example, a policy may require a subscriber to meet $1,500 deductible, after which the subscriber is required to pay 10% co-insurance. We do recommend that you contact your insurance company as they will be able to explain your specific plan in detail.
Some insurance plans have a co-insurance requirement meaning that the patient and the insurance company each pay a certain percent of the visit. If you have further questions we urge you to contact your insurance company for full details on your insurance plan.
When a claim is denied for this reason it is because your insurance believes that you have another health insurance policy that would have paid for the services. This is very common when you have changed health insurance within the last year. Some insurers require that you update coordination of benefits information every year. Your insurance will not pay the claim until you contact them and update your coordination of benefits information. They will not accept coordination of benefits information from us. To resolve this, please contact your insurance company and speak to a representative about your coordination of benefits and specifically ask them to reprocess your claim. You may have also received a questionnaire in the mail that you can complete to update your coordination of benefits information. You must update your information and ask them to reprocess your claim before they will process this claim and issue payment on your behalf. It is important to take immediate action to resolve these situations to avoid additional statement or collection fees.
Claims that are denied out for coordination of benefits information cannot be re-filed by Western Wayne Medical. If we re-file these claims they will be denied as a duplicate by the insurance company as the insurance already has the claim in their system. In these cases the patient needs to call and ensure their coordination of benefits information is up to date and also ask their insurance company to reprocess the claim.
When a claim is denied or is pending for further information for a pre-existing condition the insurance company is waiting on information from the pre-existing condition questionnaire that was sent in the mail to the patient. If you have your claim denied for this reason but have not received a questionnaire please contact your insurance company to resolve the issue.
When health insurance coverage is not in force as expected, the most successful solution is for the patient to call their insurance company and speak with a representative regarding this denial. Since the contract is between you and your insurance company Western Wayne Medical cannot address this situation. If you did have coverage at the time of your visit, please address this with your insurance company and ask them to reprocess the claim. If you had insurance coverage through a different insurance company please contact Western Wayne Medical to provide your new insurance information. We may or may not be able to file the claim on your behalf based on the timely filing guidelines your insurance company has set in regards to claims submissions. If we are unable to file the claim due to timely filing, the patient will be responsible for the full amount. Please bring the most recent copy of your insurance card to each visit to avoid this issue.
Maximum benefits is a restriction your insurance company places on the amount of money they will pay for a particular service during the policy year. Once your insurance company has paid up to their maximum for that particular service, they will deny claims in the same policy year for that service because you have exhausted your maximum benefit. Services rendered that exceed the insurer’s maximum benefit for the policy year are considered patient responsibility.
Contact our billing partner – Solutions for MD’s 1.800.990.6015