- Fees for services are generally covered, in full or in part, by most commercial insurance plans.
- For your convenience, we gladly accept MasterCard, Visa, Discover and American Express.
- Self-Pay plans are available.
- We accept Medicare and Managed Care Medicaid.
- We are an approved Bureau of Workers Compensation Provider.
Please feel free to call us with any questions or concerns you have regarding our fees or your insurance coverage. It is our customary policy to verify your insurance coverage prior to your first appointment to ensure you are informed of your financial responsibility before you initiate services.
Often understanding your insurance benefits and insurance terminology can be confusing. We want to help alleviate this confusion by explaining the most commonly used terminology by your insurance company and your medical/ behavioral health providers:
Actual Charge: The actual dollar amount charged by a physician or other provider for medical services rendered, as distinguished from the allowable charge.
Allowable Charge: also referred to as the Allowed Amount, Allowable Cost, Approved Charge or Maximum Allowable. See also, Usual, Customary and Reasonable Charge. This is the dollar amount typically considered payment-in-full by an insurance company and an associated network of healthcare providers. The Allowable Charge is typically a discounted rate rather than the actual charge. It may be helpful to consider an example: You have just visited your doctor for an earache. The total charge for the visit comes to $100. If the doctor is a member of your health insurance company’s network of providers, he or she may be required to accept $80 as payment in full for the visit – this is the Allowable Charge. Your health insurance company will pay all or a portion of the remaining $80, minus any co-payment or deductible that you may owe. The remaining $20 is considered provider write-off. You cannot be billed for this provider write-off. If, however, the doctor you visit is not a network provider then you may be held responsible for everything that your health insurance company will not pay, up to the full charge of $100.
This term may also be used within a Medicare context to refer to the amount that Medicare considers payment in full for a particular, approved medical service or supply.
Assignment of Benefits: The payment of health insurance benefits to a healthcare provider rather than directly to the member of a health insurance plan.
Benefit Year/ Benefit Period: The annual cycle in which a health insurance plan operates. At the beginning of your benefit year, the health insurance company may alter plan benefits and update rates. Some benefit years follow the calendar year, renewing in January, whereas others may renew in late summer or fall.
Claim: A bill for medical services rendered, typically submitted to the insurance company by a healthcare provider.
Copayment: A predetermined, flat fee an individual pays for health-care services, in addition to what insurance covers. For example, some HMOs require a $10 copayment for each office visit, regardless of the type or level of services provided during the visit. Copayments are not usually specified by percentages.
Coinsurance: The amount that you are obliged to pay for covered medical services after you’ve satisfied any co-payment or deductible required by your health insurance plan. Coinsurance is typically expressed as a percentage of the charge or allowable charge for a service rendered by a healthcare provider. For example, if your insurance company covers 80% of the allowable charge for a specific service, you may be required to cover the remaining 20% as coinsurance.
Coverage: The scope of protection provided under an insurance policy. In property insurance, coverage lists perils insured against, properties covered, locations covered, individuals insured, and the limits of indemnification. In life insurance, living and death benefits are listed.
Date of Service: The date on which a healthcare service was provided.
Deductible: A specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims. Not all health insurance plans require a deductible. As a general rule (though there are many exceptions), HMO plans typically do not require a deductible, while most Indemnity and PPO plans do.
Eligible Expenses: Expenses defined by the health insurance plan as eligible for coverage.
Exclusions: Items or conditions that are not covered by the general insurance contract.
Health Reimbursement Arrangement: Owners of high-deductible health plans who are not qualified for a health savings account can use an HRA.
Health Savings Account: Plan that allows you to contribute pre-tax money to be used for qualified medical expenses. HSAs, which are portable, must be linked to a high-deductible health insurance policy.
Maximum Out-Of-Pocket: An annual limitation on all cost-sharing for which patients are responsible under a health insurance plan. This limit does not apply to premiums, balance-billed charges from out of network health care providers or services that are not covered by the plan.
Network Provider: A healthcare provider who has a contractual relationship with a health insurance company. Among other things, this contractual relationship may establish standards of care, clinical protocols, and allowable charges for specific services. In return for entering into this kind of relationship with an insurance company, a healthcare provider typically gains in numbers of patients and a primary care physician may receive a capitation fee for each patient assigned to his or her care.
Non-Participating Provider: For various reasons, non-participating (non-par) providers have declined entering into a contract with your insurance company. This can mean either no coverage by your insurance company or higher deductibles, co-pays or co-insurance amounts.
Preauthorization/Precertification: These are terms that are often used interchangeably, but which may also refer to specific processes in a health insurance or healthcare context.
1) Most commonly, “preauthorization” and “precertification” refer to the process by which a patient is pre-approved for coverage of a specific medical procedure or prescription drug. Health insurance companies may require that patients meet certain criteria before they will extend coverage for some surgeries or for certain drugs. In order to pre-approve such a drug or service, the insurance company will generally require that the patient’s doctor submit notes and/or lab results documenting the patient’s condition and treatment history.
2) The term “precertification” may also be used to the process by which a hospital notifies a health insurance company of a patient’s inpatient admission. This may also be referred to as “pre-admission authorization.”
Participating Provider: Generally, this term is used in a sense synonymous with Network Provider. However, not all healthcare providers contract with health insurance companies at the same level. Some providers contracting with insurers at lower levels may sometimes be referred to as “participating providers” as opposed to “preferred providers.”
Provider: A term commonly used by health insurance companies to designate any healthcare provider, whether a doctor or nurse, a hospital or clinic.
Provider Write-off: The difference between the actual charge and the allowable charge, which a network provider cannot charge to a patient who belongs to a health insurance plan that utilizes the provider network. See Allowable Charge for more information.
Usual, Customary and Reasonable (UCR) Charge: This refers to the standard or most common charge for a particular medical service when rendered in a particular geographic area. It is often employed in determining Medicare payment amounts.