January 25, 2011

Insurance Dilemma

Insurance Dilemma
It seems like everyone these days has concerns about insurance and the cost of health care. I have been in practice for 30 years and remember “the good old days”. When I first started in private practice in Portland, Oregon in 1981, we charged $95 for an annual exam. We would be reimbursed $95. At that time, most insurance companies would pay 80% and the patient would pay 20%. There was no question and we only needed one person to do the billing. If a surgery or a procedure was needed, it was scheduled. There was no middle man for “prior approval”. Office overhead in those days was around 40%.

Now, most offices will bill $225-250 for an annual exam and we are lucky to be reimbursed $85-120 for an annual exam. Not much different from 30 years ago. A “cash” patient ends up paying more to make up for what insurance companies do not pay. We now need to have an extra employee to acquire prior approval for procedures and to schedule surgeries. We also need a person just to call and deal with insurance companies. Billing codes have to be as each company directs and claims are often denied several times before they go through. Overhead now runs 50-60% or more. Health care providers are making less money and your insurance premiums are going up. Who is making the money?
Due to these issues, many providers, including Dr. Hoppe and myself, have chosen to not be “preferred providers” for the different insurance groups. However, our prices are fair, generally $150-180 for established patients and $160-190 for new patients. We will collect the day of service (credit cards accepted) and then we will bill your insurance company for you, as a "Non-Provider". You will receive your reimbursement in 3-4 weeks. If you do not have insurance, you will be paying much less than in other offices. As you will see below, we will take Medicare. Please see the Q & A below for more details. Feel free to call the office with any questions, 760-635-5600.

  1. What does it mean that Dr. Hoppe and/or Donna Duvall is a “non-contracted provider”?
    It means that only the “in-office” portion will be billed differently.  Other services, including PAP smears, mammograms, DEXA/Bone Density Tests, as well as laboratory work will be covered by and billed to your PPO insurance.
By being a “non-contract provider”, only the “in-office” portion of your office visit with the office will change.   Payment will be due at the time of service and a receipt will be provided for you.    Most PPO insurances have “out-of-network” benefits.  These benefits will then be reimbursed to you by your insurance company.
  1. How do I know if I have “out-of-network” benefits?
    Simply call the customer service phone number on your insurance card and ask them to verify your “OUT OF NETWORK” benefits.  We will be billing your claims as “NON-CONTRACTED PROVIDER”.  You are calling to confirm that your insurance carrier will be able to reimburse you directly.
  2. Who will submit my claim to my insurance company?
    As a convenience to you, our  office will submit the initial insurance claim to your insurance company so that you do not have to.  Usually the insurance companies will send you reimbursement within 3-4 weeks after the claim has been submitted by our office.
  3. What if I do not have out-of-network benefits, or if getting these benefits would be too expensive?
    Most PPO plans provide for out-of-network benefits.  If you do not have out-of-network benefits or if changing your insurance to add these benefits would be too costly, cash discounts will be offered.  In general, office GYN annual visits range from $150 – $180 for established patients and $160 – $190 for new patients.
  4. What about PAP smears, mammograms, pelvic ultrasounds, laboratory testing and other services?  Will these be covered?
    Yes, these will continue to be covered as they presently are with your insurance.  The only change will be in billing portion of the “in-office” part of your visit/evaluation.
  5. What if I have Medicare insurance?
    Yes, you can be seen.  Medicare has stated that they will reimburse you approximately 80% of their allowable rate for services rendered and paid for.  If you have supplemental insurance, Medicare will automatically forward your claim to your supplementary insurance for the additional 20%.
  6. What if I am a “new” Medicare patient?
    Yes, Dr. Hoppe and I  will be able to take care of you and submit the bills in the same way as for the Medicare patients stated above.
  7. What about other procedures?
    Many office procedures may be covered by your out-of-network benefits.  For any procedures that may be necessary that may not be covered by your insurance company, a cash discount will be offered.
  8. What if I have a HSA account?
    Yes, these will be accepted.  There are different types of HSA accounts and these will be billed according to the criteria of your specific account.


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Shubhadip Shubhadip on July 11, 2013 3:42 AM
I worked at Med I Cal for some time, and it is often miesaktn for Medicare. Med I Cal is only available for people with children (as you have stated) not single folks, additionally you must make an income that is less than 250% of the national average.No free lunch in america for health insurance, of the 300million americans approx. 40million just don't have any.First you must understand what is available so you can make an educated decision on what to pick.1. PPO plansa. Preferred Provider Organization, most popular in Americab. Deductibles- the amount you pay before benefits are paid by the health insurance co. ex. 500 2000c. Co-Insurance- the amount you pay after you have paid the deductible. ex. 20-30% is common placed. Max. out of pocket- the most you would pay in one year including deductibles and co-insurance if you use a preferred provider.e. Co-pays- these are amounts (usually small) that you pay for Dr. Visits, RX copays. ex. 10. for generic drugsSummary, PPO plans can be offered at very low costs because high deductibles and high co-insurance means that the consumer will need to pay these high deductibles and high co insurance. It boils down to risk you as the consumer are willing to take on, I personally have a high deductible plan- you ask why? well at 44 years of age, my mother and father are alive and healthy- my grand parents are still alive so genetics are working in my favor, I live a healthy lifestyle no drugs, I try to exercise everyday -eat my vegetables, fruits like my parents. I have elected to pay as little as possible and purchase a high deductible plan meaning that I am responsible for all charges up to 3500. every year, this is called a major medical plan- and I took it one step further by purchasing a Health Savings Account Qualified plan, since I am self employed.You must understand that health insurance companies make billions, yes billions every year on people who are don't make claims. People just like me, who buy expensive plans with low deductibles lots of benefits and don't use them, it is because some slick salesperson has sold them a bill of goods. The health insurance companies don't really want you to understand the plans or people who change to high deductible plans immediately, especially HSA or health savings accounts which are just incredible.

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