As a new patient you will meet with our Patient Account Representatives and complete a patient information form and verify your insurance information. Please bring your insurance identification card(s) with you. A photocopy will be placed in your billing file. If you are covered by more than one insurance company, please let us know which company is the primary carrier. This will help to avoid any delays in receiving benefits. If there is any change in your health coverage, please contact the office to update your records.
We participate with most major insurance companies and will submit claims to your carrier on your behalf. Medicaid patients are welcome. We also accept Medicare assignment — however, you will be responsible for the deductible and your 20% co-payment for Medicare’s allowed charges for physician care, chemotherapy drugs, and laboratory tests. If you belong to an HMO or PPO plan, please verify that our physicians are in the plan before your treatment begins. Also, please inform our office if pre-certification is necessary with your plan.
Some insurance companies require you to use a specific laboratory or to obtain referrals or pre-authorization for office visits, hospital admissions, and treatment. It is your responsibility to obtain the initial referral and bring this with you on the first day of your first visit. If you need assistance with your insurance requirements, our staff will make every effort to help you.
Co-payments are payable at the time of your visit. We accept Visa, MasterCard, Discover, and American Express. We will be happy to assist you in developing a payment plan.
Please call our Patient Accounts Representative if you have questions or need assistance in coordinating and filing claims with your insurance company. Please be assured that your confidentiality will be respected at all times.
Health Maintenance Organizations (HMOs): HMOs are organized systems for providing health care in a geographic area. They have a set of basic and supplemental preventative and treatment services; members generally select a primary care physician who is responsible for making all referrals to specialists. HMOs offer no “out of network” benefits and have low out-of-pocket (co-pay) expenses.
Indemnity Plans: Indemnity or traditional insurance is not considered “managed care”. In indemnity plans the member chooses his or her own providers. Oversight of care by the health plan is minimal. The member’s out-of-pocket payment is generally a percentage of the provider’s usual and customary fee schedule.
Managed Care: A broad term that describes programs designed to manage the cost and quality of health care. Ideally, managed care brings about a comprehensive health care system where patients receive the care they need, including preventative care when they need it. The plans vary from restrictive provider panels and low out of pocket amounts to fairly open provider panels and high out of pocket amounts.
Medi-Cal: The federal state health insurance program for low-income individuals, the indigent and elderly. Many states are introducing Medi-Cal HMOs for this population.
Medicare: The federal health insurance program for older Americans and eligible disabled individuals. Medicare HMOs are beginning to be offered in some areas of the country.
Point of Service (POS): POS plans build on the HMO concept. However, if a member chooses to seek a specialist directly, without a referral from their PCP, or seeks an “out-of-network” provider, they will have coverage with a higher out-of-pocket (co-insurance) amount.
Preferred Provider Organization (PPO): PPOs generally provide “in-network” and “out-of-network” benefits and do not require a PCP referral to see a specialist. The amount the member must pay out of pocket is less when using an “in-network” provider.
Common Managed Care/ Insurance Terms
Co-payment: A flat fee paid out of pocket for medical services, usually at the time the service is rendered. Usually applies to physician office visits, prescriptions, emergency or hospital services.
Co-insurance:Coinsurance, like co-payments, is a common form of member cost-sharing, typically applied as percentage of applicable costs after the deductible requirements are met. With traditional non-managed care plans, the percentage is based upon provider charges, sometimes up to a maximum allowable amount per service. In managed care plans, the percentage can be based upon provider contract rates.
Deductible: The amount of medical expense a person must pay each year from his/her own pocket before the health plan will make payment.
Gatekeeper: When a primary care physician, the “gatekeeper”, serves as the patient’s initial contact for medical care and referrals.
Out of Network Benefit: PPOs and HMO Point of Service plans contain an out-of-network benefit tier that is different from benefit coverage for network services. In PPO plans there can be cost sharing requirements that are somewhat “hidden” in the process. For example, a number of PPO plans indicate a percentage coinsurance requirement for out-of-network, but also limit the benefit to a maximum allowable based upon average contract rates. This means the member must pay a percentage coinsurance based on the maximum allowable, plus the entire amount that exceeds the maximum.
Primary Care Physician (PCP): A PCP is a physician designated as responsible for providing specific primary care services. This includes evaluation and treatment of a patient, including decisions regarding referral for specialty care. PCP’s are generally in family practice, general practice, general internal medicine, pediatrics and sometimes obstetrics and gynecology. Under the HMO health plan model, the PCP may also be considered the gatekeeper.