INSURANCE BASICS:

Your deductible is the amount you must pay yourself towards your treatments before your health insurance company will pay anything towards your services. Before you meet your deductible, you are responsible for paying 100% of your medical bills. Once you pay a total that is equal to your deductible, your co-insurance kicks in. Co-insurance is a cost-sharing phase where you are responsible for a % of the bill until you have paid a total amount of your own money equal to your out-of-pocket max. Once you have paid an amount equal to your out-of-pocket max towards your medical expenses for the year, you will be covered at 100% for allowed charges. Note: This coverage is not the same with out-of-network providers.

IN-NETWORK INSURANCE BENEFITS:

We are an in-network provider with Blue Cross Blue Shield and CIGNA meaning we have contracted rates (also called allowed amounts) with them.

VOB/ESTIMATE

When we run a verification of benefits for an in-network health insurance plan, your insurance company tells us what your deductible, co-insurance/ or co-pay, and out-of-pocket max are currently according to their system.  If you have any claims pending that your insurance provider has not processed yet, your cost for treatment could change and would be reflected in your EOB. We use these provided categories in conjunction with our contracted rate with them to determine your estimated cost of treatment.

DENIALS

A verification of benefits is not a guarantee of payment by your insurance company, it is simply confirming that you have active health insurance coverage. If your claims deny, you are responsible for paying the full contracted rate for our services.

AUTHORIZATIONS

What is an insurance authorization?

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. ... Preauthorization isn't a promise your health insurance or plan will cover the cost.

We must go through this authorization process, so even if you have out of network or in network benefits it is never a guarantee that the service will be covered because we have to provide all clinical to insurance doctors and RNs on the rationale of why a patient needs to be in our level of care.

CLAIMS/EOB

Once your insurance company processes your claims, they provide you and us with an Explanation of Benefits. This EOB has a breakdown of the billed amount, allowed amount, and your patient responsibility. Your patient responsibility amount is calculated by your insurance and includes your deductible, co-insurance, and co-pay, and can be as high as your out-of-pocket max. When we receive your EOB, we adjust your account to reflect this patient responsibility amount. For some patients, this will mean a refund and for others it could mean an invoice to collect additional funds.

USING OUT-OF-NETWORK INSURANCE BENEFITS:

We are an out-of-network provider with most private insurance companies. This means you will be using your out-of-network benefits.

VOB

When we run a verification of benefits for an out-of-network health insurance plan, your insurance company simply tells us if you have active coverage, and what your deductible, co-insurance/ or co-pay, and out-of-pocket max are currently according to their system. If you have any claims pending that your insurance provider has not processed yet, your cost for treatment could change. This would be reflected later in your EOB.

DENIALS

A verification of benefits is not a guarantee of payment by your insurance company, it is simply confirming that you have active health insurance coverage. If your claims deny, you are responsible for paying the full contracted rate for our services.

AUTHORIZATIONS

What is an insurance authorization?

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. ... Preauthorization isn't a promise your health insurance or plan will cover the cost.

We must go through this authorization process, so even if you have out of network or in network benefits it is never a guarantee that the service will be covered because we have to provide all clinical to insurance doctors and RNs on the rationale of why a patient needs to be in our level of care.

ESTIMATE

With out-of-network providers, the payers (insurance companies) do not tell us their “allowed amount” or reimbursement rate for our services, so we calculate your treatment cost estimate based on an assumed reimbursement rate equal to our private pay rate. We will not know the actual cost of your treatment until your claims are processed by your insurance company.

CLAIMS/EOB

Once your insurance company processes your claims, they provide your and us with an Explanation of Benefits. This EOB has a breakdown of the billed amount, allowed amount, and your patient responsibility. Your patient responsibility amount is calculated by your insurance and includes your deductible, co-insurance, and co-pay, and can be as high as your out-of-pocket max. When we receive your EOB, we adjust your account to reflect this patient responsibility amount.

DISCLAIMERS

When using out-of-network benefits, there are a few situations that can occur that you should be aware of before deciding to use your benefits.

HIGH PATIENT RESPONSIBILITY

Just like most insurance companies, our billed amount is higher than our private pay rate. You should be aware, insurance companies can choose to apply up to the full billed amount towards your deductible - meaning your cost for treatment would be higher than paying our private pay rate. Your insurance can also calculate your co-insurance as a % of the full billed amount. Ultimately, this means that you could end up paying more in patient responsibility (deductible + co-insurance + copay) than our private pay rate. This situation usually occurs when you have a very high deductible and out-of-pocket max.  If your EOB comes back and your insurance company chose to max our your deductible or apply a large amount of patient responsibility, we are obligated to invoice you for the difference between the amount you already paid us upfront and the amount they reported as your patient responsibility.

MET

Please also note that even if your out-of-network deductible and out-of-pocket max are met and you are now covered at 100%, you could still owe additional funds for your treatment. This happens when the allowed amount or reimbursement rate that your insurance company pays per night is less than our private pay rate. If this occurs, we will balance bill you for the difference up to our private pay rate.