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Frequently Asked Questions about Paying Medical Bills

First let’s start with the basic definition of health insurance. Your health insurance policy is a contract between you and your health insurance company whether it is through your employer, government, or a self owned policy. It is an agreement that your health insurance company will pay for covered medical care as long as your premium is paid and you follow the contract guidelines when choosing a medical provider. The health insurance company may not pay for every bill. That is why it is very important for you to know which medical treatments your health insurance company will pay for and which expenses it will not cover. There are thousands of different medical plans across the country and it is the patient’s responsibility to find out which treatments are covered not the providers. With that being said it is the patient’s responsibility to pay for medical cost that the health insurance company does not cover. For example, in ophthalmology refraction is not covered by most insurance companies but if a patient receives the service they are still responsible for the charge even if there insurance denies the claim. Below are a few common questions many people have regarding their health insurance policy.

What are some common insurance terms I should know?

Be sure to check with your health insurance company to see how these terms apply to your health insurance coverage. Co-payment or “co-pay”: The part of your medical bill you must pay each time you visit the doctor. This a pre-set fee determined by your health insurance policy. Co-insurance: This is part of your bill (sometimes in addition to a co-pay), that is your responsibility. Co- insurance is usually a percentage of the total allowed charges of the medical bill. For example, the Medicare co-insurance is 20%. Allowed or Approved Amount: The allowed amount is the set price contracted between your medical provider and the health insurance company. The provider has agreed to accept the approved amount as payment in full and any balance over the approved amount is adjusted to reflect the contracted rate. For example, the medical provider may charge $200 for a certain procedure but their contract with the health insurance company is $170.00. The provider has agreed to adjust $30.00 to conform to contract rates. Deductible: The cost you must pay for medical treatment before your health insurance company starts to pay. For example, $500.00 per individual or $1,500.00 per family. In most cases a new deductible must be satisfied each calendar year. 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 seen the office for services and billed by the doctor’s office. Approval Number or Authorization Number: A number authorizing the health insurance company to pay benefits for your care. You may need to obtain an approval number form your health insurance prior to seeing the doctor in order for the health insurance company to pay for your medical treatment. Your doctor’s office staff might be able to help you obtain the approval number for the health insurance company.

How is my doctor’s office paid?

You should pay your co-payment or co-insurance and deductible if required, at the time of service to the doctor. While you are responsible for your medical treatment, your doctor’s office will make every effort to seek payment from your health insurance company for the amount owed under your policy. The process by which the office seeks payment can be complicated and time consuming, which is why it is very important for the patient to provide the correct information to the doctor’s office.

What information should I bring to the doctor’s office?

Your current health identification card Photo identification such as a driver’s license Any changes to personal information such as your name, address, or phone number.

If the doctor is seeing my child, what information should I bring to the visit?

Your health insurance care or the card of the person who covers the child’s medical care The name of the policy holder and their demographic information The name of the person responsible for the child’s medical care decisions and payment. The doctor’s office will also need to know your relationship to the child. It is highly recommended that the parent or guardian, accompany any minor to the office visit.

Why does the doctor’s office need my personal and health insurance information to get paid?

The doctor’s office uses this information to confirm your health insurance coverage and to send your health insurance company a request for payment of your medical bill. The health insurance company requires your personal and health insurance policy information before it will pay your bill. That is why it is very important to provide all the correct personal information requested by the doctor’s office, including given names (nicknames should never be given when it comes your insurance information) social security number, date of birth, etc. It is also important to present the most current insurance card even if you still have the same policy. Much of the information on the care may have changed from year to year including information as to where to send the claim. Not providing the correct personal and health insurance information leads to delays in claim processing and can lead to a timely filing expiration which then leads to payment becoming patient responsibility.

What is a “coordination of benefits” form?

Many people especially patients that have reached the age to have Medicare have multiple health insurance plans. Most health insurance companies require you to fill out a form telling them whether you or another family member has coverage with another health insurance company. Your health insurance company needs this information to work with your other insurance companies to determine which company pays for what service. Failure to complete a coordination of benefits form can lead to delays and denials of claims which in turn become patient responsibility.

What if the health insurance company does not pay or only pays a portion of my medical claim?

Most doctors’ offices will be glad to help resolve any issues with your health insurance company regarding denied claims or payment. The health insurance company may ask the doctor’s office to appeal or re-send the medical bill with more detailed information. This typically happens when the health insurance company has not paid for a procedure or service listed on your bill even if your doctor said it was medically necessary. You may receive a copy of you doctor’s appeal letter to your insurance company. There are occasions when the doctor’s office would like your help in resolving claims that your health insurance company does not pay. You may be asked to contact the health insurance company or policy administrator to update/change information that is required from the insurance company.

What are some common reasons a health insurance company may not pay for medical treatment?

Services were provided for a pre-existing condition. Most health insurance companies will not cover treatment for medical conditions you had prior to obtaining coverage through the current health insurance company. Your health insurance policy should discuss pre-existing conditions in more detail. Medical treatment provided to you is not covered by your health insurance policy The coordination of benefits form (see #6) or other required information has not been completed by you or submitted to your health insurance company. The health insurance premium has not been paid, either by your or your employer. A spouse, child and/or newborn are not covered under your health insurance, if he or she was not added to the policy. The doctor is considered “out-of-network” which means your doctor does not have a current contract with your health insurance company. Please be aware that if your doctor refers you to another doctor or specialist if does not mean that they are “in-network” with your current policy and you may be responsible for any charges obtained during treatment. It is your responsibility to verify any doctor’s you see are “in-network” with your health insurance company. Another health insurance policy requirement, such as obtaining prior approval (see #1) for your medical treatment, was not obtained. We value you as our patients and your health care is important to us. With the raising cost of health care it has never been more important to take some time to get to know your insurance policy and what it covers so you are not paying for charges that should have been covered. The medical billing staff at Athens Eye Associates will always strive to help answer any questions you have regarding what your policy may cover for your eye care. Please feel free to contact us anytime if you have questions regarding your health insurance or any charges that were not covered by your insurance company. We will do whatever we can to help you get the most out of your health insurance coverage.

Accepted Insurance Plans at Athens Eye Associates:

We participate in many major health insurance plans. Coverage can vary with each patient and insurance company. It is the patient’s responsibility to know his/her benefits. Many companies will allow a routine eye exam once a year or every 2 years. It is the patients responsibility to inform Athens Eye Associates of this benefit. We do not accept every vision plan associated to every health insurance plan, and not every doctor in our practice will accept vision plans. Our staff will be glad to assist you in determining your coverage and eligibility prior to you’re appointment. Below is a list of currently accepted insurance plans (if you do not see your plan listed please call us to verify we accept it, not all plans are listed):

  • Aetna
  • Amerigroup
  • Assurant Health
  • Avesis
  • Beech Street Corporation
  • Blue Cross Blue Shield
  • Care Improvement Plus
  • Cigna
  • Coventry Healthcare
  • Eyemed
  • First Health
  • GEHA
  • Health Plan Select
  • Humana
  • InStill Health
  • Kaiser Permanente
  • Medicare
  • Medical Mutual
  • Meritain Health
  • Met Life Discount Plan
  • Multiplan
  • Railroad Medicare
  • Southeast Community Care
  • The Mail Handlers Benefit Plan
  • Tricare
  • UMR
  • United Healthcare
  • Univeral Healthcare
  • Vision Service Plan (VSP)
  • Wellcare of Georgia


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