We are Here to Help

Thank you for taking the time to read our policies. Patients should not hesitate to call with any questions regarding this handbook. We wish to work as a team with our patients to ensure insurance claims are processed accurately.

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1.) Prepare for Your Visit

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Be sure to bring these items every visit:

• Insurance Card

• State/Photo ID

• Cash / Check / Credit card

• Information required to fill out forms (see Required Information section below)

 

New patients are advised to visit the Patient Portal and complete the registration information. Personal Information, Insurance, Contact Information, Medical History, Medications, Pharmacies and Social History. If unable to access the Patient Portal, please arrive 30 minutes prior to appointment time to fill out paperwork.

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REQUIRED INFORMATION

Be prepared to provide:

• Patient name, address, phone number, gender, date of birth, email, pharmacy, emergency contact insurance ID and group number.

• Subscriber name, address, phone number, gender, date of birth, relationship to patient.

• If patient is not the Responsible Party, provide the Responsible Party's name, address, phone number,,gender, date of birth, and relationship to patient. Be sure to tell the front desk that bills are supposed to be sent in the Responsible Party's name.

• For any out of state Blue Cross Blue Shield plans, please provide the state the policy is from or the plan code. Both items should be found on the patient's insurance ID card.

 

If any of this information is not provided, payment in full will be required at time of service.

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CONFIDENTIALITY

Patient information is private and protected. LPFP is HIPAA compliant.

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TIME OF SERVICE PAYMENTS

The following are expected at time of service:

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• Co-pays

• Self-insured patient payments

• Any balances aged past 30 days

• Payment for services rendered to patients whose insurance is out of network or out of the country

• Payment for services that are non-covered due to policy exclusions or a pre-existing condition

• Payment in full for services rendered to patients whose insurance could not be verified or who refused to provide aforementioned required information

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UNDERSTANDING YOUR BENEFITS

It is the patient's responsibility to understand his/her benefits and to keep us informed. This helps us better accommodate the patient at time of service and helps the patient to better anticipate any out of pocket expenses. Please be familiar with the following:

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• Exclusions on the policy, which can include pre-existing conditions

• Dollar or service maximums on any services

• Whether there is a deductible, how high it is, and what services it will be applied to

• Reason for appointment, with regard to whether it is a "Well visit" or a "Sick Visit". A "Well Visit" will be covered by Preventative Benefits and can include, but is not limited to, any preventative tests, physical exams, and immunizations. A "Sick Visit" will be covered by Office Visit Benefits and can include, but is not limited to, any visit you have with a provider that addresses a present complaint or condition. Please note whether your benefits cover these services.

• Whether your plan covers mental health benefits

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2.) UNDERSTANDING THE INSURANCE CLAIM PROCESS

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How does it work?

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1. See the provider

2. Office sends the claim to the insurance company the next business day.

3. Insurance company processes the claim

4. Insurance company sends the patient and provider an Explanation of Benefits

5. Office's billing department sends a bill to the patient for remainder of balance

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EXPLANATION OF BENEFITS (EOB)

Explanation of Benefits documents are sent by payors to both enrollees and providers after a claim is processed. This document illustrates:

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• Provider payment

• Write-offs/ Contractual Adjustment

• Patient responsibility

 

However, an EOB is not a bill; it is simply an explanation of how benefits were applied. The patient's bill will come from LPFP. Please pay promptly.

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CLAIM PROCESSING

There are four ways a patient can incur a balance:

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1. Co-pay

2. Co-insurance

3. Deductible

4. Non-covered charges due to exclusions/maximums on policy

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One or all of these balances can be incurred by any one claim simultaneously; it depends on the patient's policy. Patients are encouraged to review their EOBs to ensure the insurance company processed their claim appropriately according to their insurance benefits. See the definitions at the end of this page for a better explanation of each of these terms.

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ADDITIONAL INFORMATION

Often, before insurance companies can correctly process a claim, they request additional information. This requested information can include, but is not limited to:

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• Update of Coordination of Benefits (COB)

• The date and accident/injury occurred

• Onset of an illness/condition

• Student Status

• General records update

• Additional information may also be requested from a provider other than us

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It is the patient's responsibility to provide the additional information to the insurance company. Patients will receive a notification from their insurance and a letter/statement from us. Thirty days are allowed for providing said requested information to the insurance company before we turn the entire balance over to patient responsibility.

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3.) PATIENT FINANCIAL RESPONSIBILITIES

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PATIENT STATEMENTS

Patient monthly statements generally go out around the 15th of every month. Patients will receive a statement from us with the remaining balance once we receive a reply from the insurance company. Payment is due within 15 days of receiving the statement.

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PAYMENT OPTIONS

We require all patients to have debit/credit card information on file so that automatic payments can be made for balances due. Our office accepts Visa, MasterCard and American Express. Our office also accepts check or cash. Please do not send cash by mail. There will be a $50.00 fee for all returned checks. As of Sept.1, 2012, you can use Auto Pay via your credit card. You can also make payments through the Patient Portal.

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THIRD PARTY BILLS

In addition to receiving bills from us, patients may also receive bills for services provided by a third party. These charges may be for lab, radiology, hospital, or other services. While your provider orders these services, said third parties provide them and payment should be made directly to the third party. It is advised that patients call the third party directly with any questions.

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PAYMENT PLANS

Sometimes, unexpectedly large balances are incurred. If a balance cannot be paid in full, patients may call the office to set up a payment plan within 10 days of receiving a statement.

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How a payment plan works:

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• LPFP uses an online system to set up a payment plan that automatically deducts from an account designated by the patient

• Only a credit card or a debit card with a Visa/MasterCard logo can be used for this online system

• A maximum of six (6) deductions can be made with an amount no less than $50.00 per deduction

• Billing will negotiate with the patient the amount to be deducted, the date of first deduction, and the dates of subsequent deductions (the date of deduction has to be the same every month, i.e. the first of every month). Deductions are possible monthly or bi-monthly and will continue until the balance is paid down.

• There is a service fee of $1.50 each time a deduction is made, which is added to the total balance.

• If a plan defaults due to insufficient funds, it is the patient's responsibility to either call with a new credit card or pay the remaining balance in full at that time.

• Patients will still receive monthly statements to help track balance status.

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Patients may consider paying LPFP the balance in full with a credit card, so as to make payments at their discretion.

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OVERDUE BALANCES

We urge patients to keep their accounts current and in good standing with our office. Sending in partial or inconsistent payments is not acceptable and it will not keep overdue accounts from referral to a collection agency. If a payment cannot be made on time, it is crucial that patients call to set up a payment plan. All account balances past due will be referred to a collection agency.

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RECEIPTS

Patients receive receipts for any payment made at the front desk. It is encouraged that patients keep these receipts for their own records. Patients will receive a receipt via email if LPFP has that information.

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4.) DEFINITIONS AND COMMONLY USED TERMS

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ACCEPT ASSIGNMENT: Accept assignment means the provider has agreed to accept an in-network insurance company's fee schedule for services rendered.

 

ALLOWED AMOUNT: Contracted dollar amount a provider accepts as payment from in-network insurance company. This amount is the billed amount reduced by the provider discount.

 

BILLED AMOUNT: Dollar amount charged to an insurance company for services provided to a patient on a service date.

 

COINSURANCE: An insurance policy provision under which the insurer (insurance company) and the insured (patient) share costs incurred after the deductible is met, according to a specific formula. Coinsurance is expressed as a percentage or pair of percentages generally with the insurer's portion stated first. The maximum percentage the insured will be responsible for is generally no more than 50%. Coinsurance indicates how an insurer and an insured will share the costs of a bill that exceeds the insurance policy's deductible up to the policy's stop loss. Once the insured's out-of pocket expenses equal the stop loss, the insurer will assume responsibility for 100% of any additional costs.

 

COPAY: The amount an insured person is expected to pay for a medical expense at the time of the visit.

 

DEDUCTIBLE: The amount that an insurance policy holder has to pay out-of-pocket before reimbursement begins in accordance with the coinsurance rate.

 

DEPENDENT: An individual who is covered under the subscriber's insurance policy. Generally this individual is related to the subscriber; i.e. spouse, child.

 

IN NETWORK: Providers that have a contractual agreement with the insurance company. Being in-network means that the provider has agreed to a discounted rate for members of the contracted insurance carrier.

 

NON-COVERED/INELIGIBLE: Services that are not covered by the insured's insurance policy. The resulting charges are patient responsibility.

 

OUT OF NETWORK / NON-PARTICIPATING INSURANCE: Providers that DO NOT have a contractual agreement with the insurance company. Out of network providers will still submit insurance claims for the patient, however, the insurance company will reimburse the patient directly. Patients can still be seen by an out of network provider; however, a higher out of pocket expense can be accrued.

 

PROCEDURE CODE: Numbers or alphanumeric codes used to identify specific services provided by a medical professional. Also known as a CPT code (Current Procedural Terminology).

 

PROVIDER DISCOUNT: Difference between the billed amount and the allowed amount. Also known as a write-off or the amount above the "contracted rate" of provider payment. /

 

PROVIDER PAYMENT/CLAIMS PAYMENT: Dollar amount paid by an insurance company to the provider for a date of service.

 

PROVIDER: An organization or person who delivers health care professionally and systematically. This can include, but is not limited to, doctors, nurse practitioners, hospitals, labs, and specialists.

 

RESPONSIBLE PARTY: The party responsible for paying a patient's bills.

 

SELF-INSURED, SELF-PAY: A patient who has no insurance coverage is considered "self-insured". Self-insured patients are welcome at LPFP and are encouraged to inquire about payment arrangements.

SERVICE DATE: The date the patient was seen by the provider. Also know as Date of Service.

 

SUBSCRIBER: The party whose name the insurance policy is under; the insurance policy holder.

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We thank all our patients for their cooperation. Again, do not hesitate to call with questions.

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Thank you,
Lincoln Park Family Physicians