Insurance and Payment Options

Bundling, Covered & Non Covered Insurance Services

• Because we value our physician-patient relationship, a brief explanation is needed to alert you about the practices of some insurance companies that may impact whether the services that we render to you will be paid by them. If after reading this section, you think that you are more confused than before, then you are not alone.
  
  
• The current structure of the health insurance industry has evolved to pay for procedures and not for thinking and talking to the patient. This reimbursement model persists despite the fact that in medical school we learn that 80% of the time a good patient history will lead you to the diagnosis without any other testing. More medical students choose to go into specialties due to the reimbursement model, which further compounds the shortage of primary care physicians. This deranged payment system has often been driven by the companies that make the latest stent or new piece of radiological equipment. Of course, the doctors in our practice are grateful for new techniques and treatments but one of our goals is for you not to need them.
  
  
• The financial goal of health insurance companies is to make money for their stock holders by taking in more money than they are putting out. Paying for care now that promotes your health in the long term does not help the insurance companies meet their financial goal. Insurance companies do not look at the cost of providing a service to determine what they will pay for it. They pay the least they can get away with. If you keep up on the current news you know we are in a primary care crisis where family doctors can no longer afford to keep their doors open because of low reimbursement from insurance companies. Study after study shows that a strong primary care base actually decreases health care costs in the long run. But insurance companies are not worried about the long run – only their bottom line this quarter or this year.
  
  
• Our current health insurance system does not work. It rewards tests and procedures and penalizes physicians who spend time with patients, think about patients and actually try to balance their patient’s treatments and costs of their care.
  
  
• We don’t have all the answers but we made a commitment to be doctors and healers which takes time and unfortunately costs more than current insurance reimbursement.
  
  
• As you know, most insurance companies have very specific regulations about billing for health care services. We are obligated to follow those regulations in how we report services provided to you. All physicians and providers must report services using a variety of codes. These codes will tell the insurance company what was done and why.
  
  
• Your insurance company will only pay for "covered services" as outlined in your individual insurance contract. We will make every effort, in advance of the scheduled date, to have your insurance company verify that these service(s) will be paid, however for whatever reason (pre-existing condition, high deductibles, patient co-payments, and/or patient co-insurance percentage responsibility, etc see below) they may not pay in full or deem that these service(s) are not a covered benefit under your plan provisions or limitations and/or are "bundled" and are not paid separately.

Some reasons insurers may not pay for your care include:

1. Screening Tests: Most insurance companies do not cover a service unless you actually have a medical problem, with the exception of a Wellness Visit which just covers a "limited' number of simple screening tests. However if you want a more thorough workup with more sophisticated tests, which cost more money, such as some advance screening blood tests, a stress test, echocardiogram, vascular studies and a bone density test, they are not covered and you will have to pay out of pocket to have them done.
   
   
2. Some insurance policies cover "Wellness" Visits, but not "Illness" Care.
   
   
3. Some insurance policies cover "Wellness" Visits, but not a "Complete Physical Exam" performed by a doctor.
   
   
4. Some insurance policies do not cover both "Illness" and "Wellness" care on the same day, but will pay for both of these services if they are done on different days. As an example, during your physical exam, the doctor may need to address specific health issues separate from the exam (e.g. diabetes, high blood pressure, bronchitis, a urinary tract infection). However, some insurance companies will not pay the doctor for dealing with these issues at the same time as your physical.
   
   
5. Some insurers will not pay for a Surgical or Diagnostic Procedure done on the same day as a medical visit.
   
   
6. Some insurers do not pay family or internal medicine physicians for Mental Health diagnoses such as depression, anxiety, attention deficit disorder and others. It is also considered fraudulent if we were to disguise wellness care as illness care, or mental health care as physical care, in an effort to be paid.
   
   
7. Some insurance policies may "Limit the Level of Payment" for office visits that cover multiple medical problems and/or services. This is called "bundling" where the insurer will only pay for one or two services rendered to you when in fact more had been provided. In order to deal with this, your doctor may require that you schedule an additional office visit to accommodate all of your issues or waive that provision of your policy and agree to pay separately for those services.
   
   
8. Some insurance policies have a "Pre-Existing "Clause, which excludes coverage for any medical condition(s) which you may have been treated for in the past exclusionary period. It is not unusual for the insurance company to use this as an excuse to either delay payment pending an investigation of your past health or just not pay for your claim. Since we have no way of knowing if this may be applicable in your case, our office policy for all new patients, who have a pre- existing clause in their policy, is to assume that that a pre-existing condition does exists and we bill you for the membership price of the initial office visit. Should it be shown later on that no pre-existing condition existed and your insurance company paid for the visit, a refund will be issued.

• These negative insurance practices place the physician in an awkward position as it affects our ability to practice good medicine. Why should you be asked to make an additional appointment for something that we could take care of today? Asking you to make a return appointment is against our nature. Insurance companies have the doctor and his patient in a tough spot. We wish that we didn't have to make you schedule additional appointments, but it is important that we receive payment for the many facets of health care that we provide. The payment practices of many insurance companies do not recognize the careful effort that we put into our evaluation and treatment or your problems.
  
  
• With an understanding of these insurance company limitations, in some cases you may be able to reduce your out-of-pocket expenses by scheduling another appointment to address your specific health issues. We know that this may be inconvenient, and we personally feel dreadful that we have come to his state of affairs, but we feel the burden is on your health insurance company to reimburse the doctor fairly for the services we provide to you.
  
  
• However, in the meantime, you will not have to worry about any of these< issues if you subscribe to our PC Plan which will allow you to not have to schedule routine exams on one day, and return for separate office visits to deal with multiple or complex illnesses.
  
  
• Because there are hundreds of different insurance companies and plans, each with rules and regulations specific to the plan, it is impossible for us to know every patient's coverage exactly. Please be sure that you are familiar with what your insurance plan does and does not cover. This will prevent delays or denial in payment.
  
  
• Even though we are going to call your insurance company on your behalf to verify your coverage, we encourage you to independently call them and make sure that they agree to cover and pay for services. Based on their verification of coverage, and with the understanding that this/these service(s) are a covered, we will file a claim to your insurance company, on your behalf. However, if your insurance company later denies these benefits and/or applies these benefits to your deductible, we will then bill you for the PMC Membership discounted amount due.
  
  
• In the event that you do not have insurance, you have not met your deductible or your insurance company does not cover these services(s), we expect the payment (discounted membership rate) in full at the time the service is rendered.
  
  
• In many instances we may ask you to sign a waiver for charges related to certain health care services you receive from us, before having them performed, as this will indicate that you have been made aware of the need that these services are necessary and the reasons that your insurance company may not pay for them. In addition, when you sign this waiver, you agree to pay the portion of your bill that your insurance company does not pay. We are sorry for the inconvenience that this may cause you.