From: Dr. Felice L. Gersh, Medical Director
During the past several years, we have seen many changes involving the business aspects of medicine. In response to these changes, and after a great deal of consideration, we have decided to terminate our contracts with insurance companies. In short, this means that after August 31, 2007, (except for Medicare, TRICARE and TriWest members) we will require payment for services at the time of your visit, similar to the way medicine was practiced in the past.
The reason for this change is simple: we have reached the breaking point with the complexity of the claims processing systems and the bad faith business practices of many insurance companies. Nationally, it is reported that over 30% of claims submitted by physician offices are not reimbursed after they are initially received. Recently, we submitted an electronic insurance claim to a company for the third time after receiving filing confirmations on each of the previous occasions. When we followed up requesting payment, which is now many months overdue, we were blithely told that none of the claims had ever been received. We have just submitted this claim a fourth time with no greater expectation that it will be paid than in the past.
As I’m sure you are all aware, insurance billing processes have become progressively more complex and time-consuming with each passing year. We now find ourselves forced to choose between committing our limited resources toward maintaining and improving patient care or hiring more staff to chase down “lost” and denied reimbursement claims. It occurs to us that we are a medical office, not a collection agency. Our focus should be, and will be, on patient care, not on dealing with insurance companies’ shenanigans.
What does this mean for you?
When you visit our office after August 31, you will be expected to pay in full (by cash, check, or credit card) for the services received, before you leave the office. You will also be given a coded superbill, which you can then submit to your insurance company for reimbursement. Quite frankly, we find that insurance carriers are much more conscientious and prompt when dealing with you, their customer, than when engaged in adversarial transactions with physician offices.
How do you submit a claim to your insurance company?
It’s easier than you probably think. Simply contact your insurance company for a “Patient Claim” form (available at most insurance company Web sites) and bring it to your appointment. We will help you fill it out and put it in the mail for you. And just in case you forget, we keep a stock of universal claim forms on hand.
How much more is this likely to cost you?
That’s hard to say, since each plan sets its own rates for out-of-network payments. Your best bet is to check your policy or call your insurance company to find out what your specific coverage is. We can, however, offer these guidelines:
First, during the past five years, deductibles have skyrocketed. It is not unusual to find plans with $250, $500 all the way up to $5,000 annual deductibles. In these cases you end up paying the full bill, whether we submit the claim or you do. We have kept our charges close to insurance-company reimbursement rates so that your actual out-of-pocket payment for services will be virtually the same.
Second, some insurance plans reimburse out-of-network providers at close to the same rates as in-network providers. In these cases there may, or may not, be a small additional cost to getting your care at our office. If your co-pay is more than the difference in the reimbursement rate, then it will likely cost you less to come to our office now than it has in the past.
On the other hand, some of the least expensive plans reimburse at less than 50% of their contracted rates. For example, we charge $75 for a typical office visit with a Nurse Practitioner. If the insurance company’s contracted rate is $50, then they may reimburse you only $25 (50% of $50) for the visit. But if you have a $35 co-pay (which we no longer collect, since we are out-of-network), then, assuming you had already met your annual deductible, the actual cost of coming to our office versus going anywhere else is only $15 extra. (You no longer pay the $35 co-pay, and you are reimbursed $25 of the $40 balance.)
Of course, if you transfer to another office, you may be charged for a “new patient” visit, which typically runs around $250. If you haven’t met your deductible, you might pay this total amount for your visit. If you’ve met your annual deductible and are on an 80% plan, then you would pay your $35 co-pay and 20% of $250 ($50), for a grand total of $85. That’s $35 more than the cost of coming to our office in the above example ($75 minus the $25 reimbursement.) It’s a crazy system, but that’s the way it works.
We sincerely hope that you will continue to rely upon us for your healthcare needs. We make every effort to provide superior medical care in both a pleasant environment and a convenient location. I think you will also find that we are remarkably affordable, as well.
If you have any questions concerning this transition to a cash-only payment system, please call our Office Administrator,