Billing Process

We are committed to providing you with the best health care we can. Unfortunately, forces outside all of our control have enormous influence on our ability to take care of you. The rules, regulations, and contracts of the health insurance industry have resulted in extraordinary waste.

The Process
Every service a physician performs is associated with a numbered procedure code called a CPT code. After each office visit, we electronically submit a claim to your insurance company listing these CPT codes, along with an ICD-10 diagnosis code, a date of service, and a charge. We usually receive a response from Medicare, Blue Cross Blue Shield, and Aetna within 1 month, and 2-6 months from the other companies (United Healthcare, CIGNA, Humana, and Private Healthcare Systems/PHCS). They decide what will be covered and what will not be covered based on the terms of your policy. Even the same type of insurance has different coverage based on the individual’s or family’s contract with the insurance company.

After the insurance company adjudicates your claim and writes off anywhere between 30% and 60% of our charges, they notify us what they have decided to cover. You get a copy of this statement, which is called the explanation of benefits (EOB) and it explains what was paid to the physician, applied to your deductible, or is your responsibility.

If your insurance company does not cover 100% of your examination, we will bill you for that difference minus any contractual write-offs. Your coverage depends on your particular policy. That is why it is very wise for you to understand what your policy does and does not cover.

If the insurance company states that a test is not covered, we will transfer those charges to you.

At this point in the billing process, a statement with your outstanding balance is mailed to you and our expectation is that this will be paid promptly. You can send us a check or send or call in your credit card information.

If you choose not send your payment, we will send a second courtesy statement.

If you do not respond to the second payment request, we will be forced to send the account to our collection agency for your balance plus collection fees, which increases the charge by another 28%. We will also ask you to find a new medical practice.

Insurance companies cannot practice medicine
An insurance company cannot state that a test is not medically necessary and tell you that you don’t have to pay the charge. An insurance company cannot practice medicine, they can only decide what they will cover.

We do not perform unnecessary studies. Our commitment is to provide you with the best service we can based on sound scientific and medical principles. Our decision-making is based on what is best for you, not what your insurance company covers.

Remember, it took state laws to get coverage for mammograms, colonoscopies, Pap smears, and PSA levels. It will continue to be like that in the foreseeable future. All new technologies will be denied by insurance companies, which in effect deprive you of state-of-the-art diagnostics.

We try to practice using state-of-the-art knowledge and technology. We commit to doing what is right for you.

Why are payment policies more stringent than before?
The cost of billing insurance companies and trying to collect balances from patients has become an unaffordable cost to ALL small offices. That is the main reason why so many primary care practices have sold to the hospital systems. To stay in practice, we, like any business need to be paid.

We have tried to make it easy, by allowing credit card charges, which can be paid on the phone, via the mail, or in person. Unlike other healthcare institutions, we do not send you a bill until your insurance company has told us what you will owe. So, please pay the bill promptly when it arrives.

Otherwise, few options are left to us except to add interest, cancel existing insurance company contracts, or request payment from all of our patients at the time of service. These are things we do not want to do, but we are coming to that point rapidly. We are a small business and we have to meet our financial obligations as well.

If you confront financial problems, it is essential that you contact us and we will try to work with you.