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Billing and insurance FAQ


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Our patient accounts staff answers to frequently asked billing questions at Summit Medical Group. Topics include bringing your insurance card to all medical visits, the ABC's of co-pays, deductibles and co-insurance, and the difference between in-network and out-of-network services.

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Billing and insurance FAQ

  1. 1. Billing and Insurance Presented by: Revenue Cycle Department August 7th 2013
  2. 2. Objectives Present an overview of insurance and the billing process Answer some of the questions most frequently asked by our patients Let you know about the resources Summit Medical Group has available to assist you with your billing concerns
  3. 3. Accurate Billing Starts with your Insurance Card • Wrong insurance information delays processing of claims and leads to billing errors which can be reflected in your statement. • Bring all your current insurance cards to every visit. • Notify us when you have a change in insurance, address, or phone number.
  4. 4. Insurance-C;recent Insurance Cards Video
  5. 5. Participating Insurance Plans • Aetna • Aetna Medicare • Amerihealth • Anthem BCBS • CHN • Cigna • Coventry (First Health) • Empire BCBS • Great West • Horizon • Horizon Medicare • Magnacare • Medicare (Traditional) • Railroad Medicare • Oxford Freedom • PHCS/Multiplan • Qualcare • United Healthcare
  6. 6. Medicare • Traditional Plans • Medicare Advantage Plans  Aetna Medicare  Horizon Medicare Blue
  7. 7. Non-Participating Plans • Oxford Liberty • GHI/Emblem Health • All Other Medicare Advantage Plans
  8. 8. ….but there are always exceptions! • Oxford Liberty participating at some locations. • GHI/Emblem Health participating when the Qualcare logo is on the front of the card. • United and Oxford Medicare Advantage plans participating at some locations.
  9. 9. Look for insurance information on the Summit Medical Group website Summit Medical Group website
  10. 10. Intention of the Visit Summit Medical Group providers do not code your visit according to your benefits. The provider codes according to what was done during the visit. In addition to the physical or office visit you may be billed for lab work, x-rays, and other diagnostic testing
  11. 11. How a Service is Coded You scheduled a routine colonoscopy • Screening – no family history, no symptoms • When billed as a screening there is no cost sharing to the patient • During the procedure a polyp is detected and removed. • The diagnosis changes from routine to diagnostic • Cost sharing now applies
  12. 12. Know Your Benefits Always check with your insurance carrier to confirm your benefit coverage
  13. 13. A Few Questions to Ask • Is my provider participating in this plan? • Am I required to select a PCP, Primary Care Provider? • Does my plan require referrals? • Is this a covered benefit under my plan? • What will my cost sharing be?
  14. 14. What is Cost Sharing? Cost sharing is the patient balance that remains after the insurance plan has applied payment for covered services according to your benefit plan. It is the amount you are expected to pay.
  15. 15. What does it include? Cost Sharing includes: • Copay • Deductible • Coinsurance
  16. 16. COPAY • A fixed amount you pay for a covered health care service , to be paid when you receive the service • The amount can vary by the type of covered health care service. • $15 primary care • $25 specialist Primary Care Visit Allowed Amount $100.00 Insurance Pays $ 85.00 Patient Copay $ 15.00 Specialist Visit Allowed Amount $100.00 Insurance Pays $ 75.00 Patient Copay $ 25.00
  17. 17. Deductible • The amount the patient owes for healthcare services before your health insurance plan begins to pay • Deductible may not apply to all services • Deductibles are applied annually Plan Deductible $1000.00 Your plan won’t pay anything until you’ve met your $1000.00 deductible for health care services subject to the deductible
  18. 18. Coinsurance Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for the service Co-insurance plus deductible may apply in some cases Allowed Amount $100.00 20% Co-insurance $ 20.00 Insurance Pays $ 80.00 Allowed Amount $100.00 Deductible $ 20.00 20% Co-insurance $ 16.00 Insurance Pays $ 64.00
  19. 19. Cost Sharing Tools Most commercial Health Insurance carriers have cost estimators on their websites to help you estimate your out-of-pocket expense. • Calculate your estimated costs for procedures, office visits, lab tests, and surgeries. • Compare what your cost sharing will be at different providers and locations.
  20. 20. Medicare Cost Comparison Medicare also provides transparency into healthcare costs on their website • You can compare hospital pricing for hospital inpatient and outpatient care • The annual Medicare and You booklet also provides insight into Medicare covered benefits Visit the Medicare website:
  21. 21. Your Billing Statement • Statements go out every 35 days • You will receive a statement when your balance is $10 or greater. • Summit Medical Group bills patients according to the Explanation of Benefits (EOB) that we receive from your insurance carrier. • Match your EOB to the Summit Medical Group statement to verify that you have been accurately billed.
  22. 22. Explanation of Benefits Happenings-Understandi;recent Understanding EOB video
  23. 23. How to Read your Statement
  24. 24. How are my Payments Applied The copays you pay at the time of service are applied to that date of service. In some cases your copay may be applied to an outstanding balance for a different date of service. This is done to prevent older balances from aging and going to collections.
  25. 25. Convenient Ways to Make a Payment • Mail a check to the payment address on your statement. Sorry no credit cards by mail. • Call Patient Accounts at 908-790-6500 • Make a payment at your next visit to any SMG location • Make a payment on-line at Summit Medical Group website
  26. 26. Pre-Collection Process • You will receive 3 statements before balances are flagged at collect status • Statement messages indicate the aging of your statement balance
  27. 27. Statement Messages Second Statement: • Your account is overdue; please pay this balance immediately. Third Statement: • Your account is in collections status; please contact the office immediately.
  28. 28. Collection Letters You will receive a separate letter from Summit Medical Group when your balance is billed on a second and third statement. The letter is to remind you that your account is in collect status and if the balance is not paid it will go to our outside collection agency.
  29. 29. Collection Policy • Summit Medical Group does send aged balances to a collection agency. • Summit Medical Group has contracted with Simons Collection Agency to help us recover unpaid patient balances. • Account balances are sent to the collection agency after you receive 3 statements and you do not make a payment.
  30. 30. What to Expect from the Collection Agency • Patient receives automated and live calls from the agency. • Collection balance is not reported to the credit bureau until 90 days after placement with the agency. • Payments can be made directly to Simons or to Summit Medical Group. • Simons will update Summit Medical Group records to show your payment was made and clear your balance.
  31. 31. We are here to help • Assist you in Understanding your statements • Offer payment plan options • Provide Financial Counseling • Summit Medical Group is a billing resource for our patients; however, your Insurance Plan is and should be the first resource for questions about your benefits.
  32. 32. Patient Accounts Department • Patient account specialists are available to answer your questions and take your payments over the phone Monday – Friday • 9:30 a.m. to 4:30 p.m • Phone number: 908-790-6500 • Billing e-mail:
  33. 33. Financial Counselors • Located at 1 Diamond Hill Road, Berkeley Heights in the Lawrence Pavilion. • 150 Floral Avenue, New Providence • Appointments can be made for on-site visits. • Walk-ins are also welcome. • Annette Austion-Brown 908-790-6596 • Courtney Parker 908-273-8896 • William Stratton 908-273-8957
  34. 34. Thank you Questions
  35. 35. Participating Plans • Although we participate with these plans benefits vary depending the group package – Use Oxford Liberty as an example • Some services may be considered non-covered services based on your individual plan • Check with your insurance carrier for confirmation of benefits and cost sharing • Information received is not a guarantee of payment
  36. 36. HMO • Most HMO plans require you to select a Primary Care Provider – PCP • Primary Care Provider is a doctor whose specialty is Internal Medicine, Family Medicine, or Pediatrics • Patients can select their PCP or change their PCP by calling the health plan. • Some HMO plans do not have out-of-network benefits.
  37. 37. Referrals • Some plans may require a referral from your PCP to a specialist or facility • Summit Medical Group will get the referral for our patients who have selected an SMG provider as their PCP • Patients who have selected a PCP outside SMG must get a referral from their PCP
  38. 38. Authorizations • Some services such as Imaging or Surgery may require prior-authorization under the terms of your health insurance plan • Summit Medical Group will obtain the authorization for procedures ordered by our providers as required by your plan
  39. 39. Medicare There are two main ways to get your Medicare coverage • Traditional Medicare • Commercial Medicare Advantage plans
  40. 40. Decide how to get your Medicare Coverage Traditional Medicare includes: • Hospital Insurance (Part A) • Medical Insurance (Part B) You will need a separate plan for your Part D, Prescription Drug Coverage Medicare Advantage Plan: • Combines Part A, Part B and usually Part D
  41. 41. Understanding Benefits Cont’d • In addition to the physical or office visit you may be billed for , lab work, x-rays and other diagnostic testing, procedures • Your insurance carrier may apply co- insurance and deductible to some of these procedures in addition to your co-pay for the visit • Authorizations; Waivers and ABNs