Health Insurance Explained

We work with all insurance plans!

We are considered "Preferred Providers" and are contracted with:

PPO Plans:
- Aetna
- Anthem Blue Cross
- Blue Shield of California
- CIGNA
- Health Net
- United HealthCare

Health Maintenance Organization (HMO) Plans:
Mills Peninsula Medical Group
Palo Alto Medical Foundation

Medicare

Government Issued Photo Identification, such as a driver's license or passport

Current Health Insurance Card, if applicable

Credit Card: Visa, MasterCard, or American Express

The practice uses this information to confirm your health insurance coverage and to send your health insurance company charges for payment of the services provided.

For your convenience and to simplify billing, the practice maintains credit cards securely on file. This facilitates payment of outstanding charges, (such as copayments and deductibles), and the creation of monthly payment plans; we will notify you before submitting charges to your card.

Your health insurance policy is a contract between you and your health insurance company, stating that they will pay for covered medical care as long as your policy is in effect.

The health insurance company may not pay for every bill; you are responsible for paying any medical costs that the health insurance company does not pay for.

Deductible: The cost you must pay for medical treatment before your health insurance company starts to pay, for example, $500 per individual or $1,500 per family. Deductible amounts generally must be met yearly.

Co-Payment or Co-Pay: A fee determined by your health insurance policy that you must pay each time you visit the doctor.

Co-Insurance: A percentage of the total medical bill, in addition to a copayment, that you must pay. Co-insurance is usually expressed as a percentage of the total medical bill, for example 20%.

Non-covered charges: Costs for medical treatment that your health insurance company does not pay. You may wish to determine if your treatment is covered by your health insurance policy before you are billed for these charges by the doctor's office.

If the practice does not participate with your health insurance plan, payment in full is due at time of service. The practice accepts all major credit cards, cash, or check. Payment plans are available on an individual basis.

For participating insurances, the practice is obligated to collect the co- payment, co-insurance, deductible, and any non-covered services at the time of service.

The practice then submits charges to contracted insurance plans, which are settled as per your insurance policy, and then the insurance company will pay the practice. Sometimes, exact coverage cannot be determined until the insurance company receives the claim.

Some insurance plans require prior authorization or approval to be obtained before they pay for certain services. The rationale behind these coverage decisions varies from policy to policy.

Two important notes:

1) Prior authorization is never a guarantee of payment or coverage.

2) Just because an insurance company does not cover a service does not mean that it is not medically necessary.

Remember, they are a health insurance company, and not a doctor!

Patients are encouraged to contact their insurance plans for clarification of benefits prior to treatment.

The most common reasons that patients receive an invoice from our practice are:

1. Their health insurance plan has a deductible, co-payment, or co-insurance amount that is required to be paid before the health insurance plan provides payment, or

2. Their health insurance plan has denied payment for a service the doctor and practice has provided (usually for administrative or cost-saving rather than medical reasons).

After your office visit, procedure, or surgery, you will receive a statement called an Explanation of Benefits, or EOB, which itemizes the fees and allowable amounts covered by your insurance company.

After receiving the EOB, you will receive bills from your Surgeon, Anesthesiologist, and the Surgery Center. Consistent with the EOB, our center's bills show the amounts you are responsible for, as determined by your particular insurance policy, less any payments you've made.

The health insurance company may not pay for every bill; you are responsible for paying any medical costs that the health insurance company does not pay for.

As a courtesy to you, the practice will contact the insurance company to determine why the medical bill was not paid.

Health insurance companies will occasionally reimburse LESS than the actual cost of providing the service, usually for administrative or cost-saving rather than medical reasons.
In those cases, our billing team will contact the insurance company to correct the situation, and if unsuccessful, will charge the patient for the difference.

We work for patients, not insurance companies, and we feel insurance companies act unethically when they underpay or deny coverage.

Another version of this question starts with: "I called my insurance and they said they "paid the full allowable." Why am I receiving a bill?"

The most common reason for non-payment is patient responsibility: under the terms of the policy, a copayment, coinsurance, or deductible is still owed.

The second most common reasons is that the doctor is out-of-network, which means your doctor does not have a contract or agreement with your health insurance company.

Other reasons are:

Your policy may require prior approval or pre-authorization for your medical treatment.

Medical treatment provided to you is not covered by your health insurance policy.

Services were provided for a pre-existing condition.

The health insurance policy has changed because of employer participation or has expired.

A family member is not covered since they were not added to the policy.

In the event that you have financial difficulty paying your surgery center bill, our representatives will assist you in creating a payment plan, or making other financial arrangements. Our goal is to help make your experience as painless as possible. We certainly don't want financial issues to get in the way of your physical recovery.

Both HMOs and PPOs maintain a network of doctors, hospitals, medical labs, and independent physicians' groups to provide health care for members.

HMOs attempt to reduce costs by applying specialized management techniques to limit what they regard as unnecessary or inappropriate medical procedures.

Both share the goal of reducing health-care costs by focusing on preventive care and general health promotion.

PPO: PPO members do not have to choose a PCP and can refer themselves to any specialist in the PPO network. You can even go to a physician outside the network, but you'll pay a greater portion of the bill. So, although you're covered for services both inside and outside the network, there is financial incentive to receive care from the plan's preferred providers.

HMO: HMO, or Health Maintenance Organizations attempt to reduce costs by applying specialized management techniques to limit what they regard as unnecessary or inappropriate medical procedures.

When you join an HMO, you choose a primary care physician (PCP), who is your first contact for all medical care needs. Your PCP becomes the physician who directs what care is given, how much care is given, and by whom the care is given. HMO members must choose a PCP from among the HMO network physicians, and coverage is limited to specialists who are part of the HMO Network.

So if your family doctor or specialist, is not part of the HMO Network, the insurance company generally will not pay for care.

PPO: You are free to see any network specialist at any time. If you go outside the network, your portion of the payment may be slightly higher, however this is mitigated when comparing surgery center to hospital costs as surgery centers are generally much more efficient and economical than hospitals.

HMO: Your PCP provides your general medical care and must be consulted before you seek care from another network physician or specialist. This screening process helps to the HMO control costs.

PPO: PPO members are not required to seek care from PPO physicians, but there are savings incentives to do so for office visits and in office procedures.

For example, the PPO may reimburse 90 percent of the cost for care received within its network, but only 70 percent of the costs for non-network care.

Most PPOs give full coverage for emergency treatment regardless of where it is performed and who provides it.

Getting healthcare covered outside your network can be almost impossible with an HMO.

HMO: HMO members typically receive all treatment from their HMO network physicians. However, your HMO will pay for care provided by a non-HMO physician in an emergency. You should notify your PCP as soon as possible to coordinate the care. Nonemergency out-of-network care generally isn't covered. But your HMO will pay for treatment when it is medically necessary and when the plan's providers are normally unable to offer that treatment.

PPO: Patient responsibility is usually broken down into two components, a copayment and coinsurance.

A copayment is an amount due whenever you see a Doctor, usually $20-$50.

Coinsurance is a percentage of your bill that you are responsible for, usually 10-30%.

Keep in mind that these amounts will vary among PPOs.

HMO: Instead of deductibles, HMOs often charge a minimal amount, known as a co-payment, for each treatment or doctor's visit. HMO members often pay a nominal co-payment of $5, $10, or $20 for office visits, tests, and prescriptions.

PPO: Health-care costs paid out of your own pocket (deductibles and co-payments) are limited to an annual maximum. Typically, your out-of-pocket costs for network care are capped at various amounts for individuals and families. If you are treated outside the network, you'll of course pay more. The maximum annual cap for non-network treatment is approximately twice the amount of network care.

HMO: There is typically no limit on the amount of health-care costs in a given year. These costs are usually minimal co-payments (typically at most $20 per office visit or treatment), so your out-of-pocket expenses will probably be quite limited. But keep in mind that while some HMOs will cover specialized treatment from non-network physicians when the HMO itself doesn't provide such treatment, others will not. You could end up paying for this treatment yourself. Talk to your insurance carrier or your employer's plan administrator.

It depends.

PPOs tend to be more flexible and are generally a better choice for most consumers.

HMOs are generally less expensive.

Because you don't need to get a referral before seeing a specialist, you might prefer a PPO if you have a medical condition that requires specialized care.

But if ongoing out-of-pocket costs are a major concern, an HMO may be a better choice-there are no deductibles, and co-payments are typically lower.