For an appointment call:
833-292-BONE (2663)

 

Dr. James Wittig
Office Information
Insurance Questions


Q & A

What does 'usual, customary and reasonable' mean?

Each insurance carrier has an established payment rate for each test, procedure, or other medical service depending on the provider's geographical area. The insurer arbitrarily decides what is appropriate, approved or allowed. Unfortunately, the insurer's determination may not reflect our current costs to provide a quality service to you. This rate can be called either usual, customary, and reasonable (UCR), or reasonable and customary. Each insurance company differs from each other in what they consider customary and reasonable. Dr. Wittig's charges may be different from what an insurance carrier decides is customary and reasonable. Patients are responsible for paying any difference between our charges and the carrier's payments. This is referred to as balance billing. In many instances, Dr. Wittig's office is capable of negotiating an acceptable rate of reimbursement to minimize and sometimes negate the amount that is balance-billed to the patient.

Insurance Preauthorizations

Most insurance companies require Pre-Authorization for a patient to undergo radiological studies, biopsies and/or surgical procedures. In addition, your insurance plan (usually an HMO) may require a Referral from your primary care physician (PCP) to undergo the study, test, biopsy and/or surgery. This referral is in addition to the Pre-Authorization. With most insurance providers, the authorization process can take up to 72 hours, and in some cases up to one week. Because of the uncertain turn-around time to obtain a Pre-Authorization, it is not possible to schedule radiological studies or surgeries until the Pre-Authorization has been obtained. If a Pre-Authorization is denied, additional time will be needed to appeal the denial. Our office appreciates your patience during this process, and will submit all the required paperwork for an authorization within one day of your visit. Our staff will work diligently to obtain the Pre-Authorization from your insurance provider as quickly as possible. It is the patient's responsibility, however to obtain the referral.

In instances where Pre-Authorization is delayed by the insurance company, it is often beneficial if the patient ( who is also the Consumer ) calls the insurance company directly to discuss the Pre-Authorization with the insurance company's representative. From our considerable experience with insurance providers, we have found that when the patient/insurance company client is involved, the process is expedited significantly.

We request that all patients contact their insurance provider in advance to determine if a Referral in addition to a Pre-Authorization is required.  If so, you will need to obtain the Referral from your primary care physician and bring this Referral with you at the time you undergo the test, appointment, biopsy, procedure and/or surgery.

Referrals

A Referral is a document usually obtained from your primary care physician (PCP) which gives permission for you to undergo a specific procedure, radiological test or be seen in another physician's office (usually a specialist) for a consultation. It is the Patient's responsibility to obtain all necessary Referrals from their primary care physician (PCP) and/or insurance companies for any office appointments, radiological tests, biopsies, surgeries and/or other procedures.

Office Appointments: All Referrals for office appointments and consultations should specify that the appointment include X-rays. If this is your first appointment, the Referral should include a biopsy, as well as an X-ray.

Failure to obtain/provide appropriate Referrals: All bills or insurance claims incurred by a Patient that are not paid by their insurance carrier due to the Patient's failure to provide an appropriate Referral Form will become the financial responsibility of the Patient. After payment is received by the office, a receipt will be provided to the Patient, which may be submitted to the insurance carrier to attempt reimbursement.


Glossary of Insurance Plans

HMO (Health Maintenance Organization) - There are many different types, and they are the most complex to understand. Generally speaking, health care expenses are only covered by an HMO if a patient goes to a provider (doctor or specialist) within their organization (network). HMOs may or may not require the selection of a primary care physician, who will then coordinate a patient's care. Seeing a specialist generally requires a primary care physicians approval, and the HMO must grant approval before a hospital stay (unless in the case of an emergency). HMO is the least expensive to the consumer to purchase of all the managed care plans, but an HMO has more restrictions and takes more has total control of your medical care.

PPO (Preferred Provider Organization) - Typically more flexible than an HMO, they are usually more expensive to purchase. Patients can see any physician or specialist they want with the understanding that co-payments, co-insurance and/or deductibles will be higher.

POS (Point of Service) - A combination of both an HMO and PPO whereby a patient can see a physician within the plan and pay a small co-payment. If a physician is seen out of the plan (out-of-network) patients are expected to pay a percentage of a remaining charge after a deductible has been met.

Traditional Indemnity Insurance - These plans are the traditional form of health insurance. No restrictions are placed on physicians or hospitals or providers. Although, the most expensive of plans it allows the most freedom to choose the physicians and specialists (provider) you want and then be reimbursed for a percentage of the charge once the deductible has been met.

*Keep in mind that no matter what type of managed care plan you have chosen, you are ultimately pre-paying for care that you may or may not need but when that need does arise you have the right to fight for your interests and seek the best care possible.

Interesting resources/articles on insurance:

Top-paid health care bosses
Wednesday, March 12, 2008
http://www.bostonherald.com | Local Coverage

Andrew Cuomo takes on Insurers
February 28, 2008
click here

OPINION | February 18, 2008
Editorial: A Rip-Off by Health Insurers?
click here

Copyright 2014 by Tumorsurgery.org
   
   
 
   
    
 
 
   Website Translation Widget

    Google+