Health Insurance Explained

We work for patients, not insurance companies.
We work with all insurance plans, unfortunately not all insurance plans choose to work with us!

We are considered "Preferred Providers" and are contracted with all major PPO plans:

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

San Mateo Podiatry Group and the doctors of the group participate with Medicare.
We are not contracted with any Medicare Advantage Plans.

The following documents are required for us to create your chart:

• 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.

We value YOUR time and keep cards securely on file for the convenience of our clients; We will always notify you before submitting charges to your card.

Please let our team know which card you would prefer to use!

We'll always tell you in advance how much your office visit and any applicable treatments will cost.

For clients using their health insurance coverage, we will perform a complimentary benefits check and provide an estimate. Generally, clients pay their cost-share and any non-covered services.

Your cost share includes your co-payment, deductible, and co-insurance; our complimentary benefits check can define these amounts for you.

Self-pay clients benefit from our in-office savings plan, which offers discounts over paying per-visit.

Your health insurance has a cost-share with you, the patient and policy holder. These are amounts that your health insurance requires you to pay before they will.

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.

We're experts at helping patients maximize their benefits and working with health insurance.

With our extensive experience, expertise, and complimentary benefits check, we know your cost-share amounts, and that your insurance requires us to collect those amounts at time of service.

Please let our team know if you'd prefer to take care of this before your visit, or after, and which card you would prefer to use!

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.

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, we will contact your insurance to determine why the medical bill was not paid.

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

The second most common reason would be that this service is a non-covered service by your insurance company.

Other reasons are:

• The Doctor may be out-of-network, which means your insurance has chosen to limit the doctors it works with to be more profitable.

• 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.

If you have a balance, it's either because of your cost-share or a non-covered service.

Please let our team know if you'd prefer to take care of this before your visit, or after, and which card you would prefer to use!

We are EXPERTS at helping patients understand their health insurance and maximize their benefits.

There is NO health insurance that actually "covers everything at 100%"...

... unless the card says "American Express" on it and it happens to be gold, platinum, or black 😂.

We ask you to realize that we work 100% for our patients, not for an insurance company.

The treatment we recommend will ALWAYS be based on what is best for YOU, NOT what your insurance chooses to pay for.

We are experts at helping patients understand their health insurance and maximize their benefits. Our team has literally called insurance companies THOUSANDS of times.

Health insurance call centers provide basic and sometimes inaccurate answers. Frequently, the representative does not understand the insurance company's coverage policies, and will answer only in vague and general terms. Remember, they're a health insurance company, not a Doctor or Doctor's office.

First, they may ask for a five digit CPT code; newer technologies often don't have one.
Second, the response is usually "This is covered, subject to the terms of your policy."

A couple of points:
• Covered does not equal paid; remember, your health insurance plan has a cost share with you.
• The call center rep is usually unaware of a specific payer policy that excludes certain treatments.
• The call center rep will never have the authority to "bind" or "guarantee" coverage or payment.

Health insurance is a great benefit for many patients, and we want you to know that we will do everything in our power to ensure you get every benefit allotted in your insurance contract.

There is research and evidence that shows that health insurance policies are written to be confusing and often delatory; and these delays may cause adverse health outcomes for patients.

Some great questions to ask a call center rep:

• There is no CPT® code for this procedure. How can I submit a claim?
• Can you certify medical necessity for this procedure?
• Does my policy consider this medically necessary?
• Can you certify coverage for this procedure?
• Does my policy provide coverage for this procedure?
• Can you certify payment for this procedure?
• Can you certify the payment amount for this procedure?
• What is the payment amount for this procedure?

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?"

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.

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.

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.

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.