An Explanation of Our Financial Policy
As doctors and staff, we are passionate about what we do, and feel that we have a calling to provide as many people as possible with the highest quality health care and customer service possible. Our office aims to be convenient to you with our central downtown, retail location in our ability to see you as a walk-in patient, usually within minimal waiting times. We feel this sets us far apart from other nearby clinics who are not able to accommodate same-day appointments or spend the amount of time and give the attention to detail that we strive to provide. We have prepared this information to answer questions you or your family members may have about the rationale for our financial policies. If, after reading this, you still have questions, feel free to speak with our staff.
What Does “Out- of- Network” Mean?
If you have insurance, you often have a choice in who you select to see for your medical care. If you select to see someone “In-Network” it means that you pay a co-pay, the doctor’s office submits a claim to your insurance, and the doctor gets paid an additional agreed upon amount directly from the insurance company with whom they have a contract.
If you select somebody “Out-Of-Network”, then you are responsible for paying for that visit upfront, you submit the claim to your insurance provider and they send you a check for reimbursement. The amount they reimburse depends on your particular agreement, deductible, and plan, but the average is 70%. An example of how this works is illustrated below:
In-Network cost: Co-Pay/Total Out of Pocket $30
Out-of-Network cost: New Patient Office Visit $120 (Established Patient $110)
Reimbursed amount $84.00 (=$120 x 70%)
Total Out of Pocket $36.00
The difference between seeing in-network and out-of network is generally only $3-6!
We hope that difference is worth a same-day appointment, ability to walk-in, reach our staff easily by phone or email, and convenient to your location!
More information about typical fess and reimbursement can be found at www.fairhealthconsumer.org
Why We Do Not Accept Insurance Assignment
Many people who have contacted our office for our services have asked us why we do not bill insurance directly when other medical providers do. We fully understand the financial challenge this presents to some patients, and we wish there were a way for us to bill your insurance company. Unfortunately, at this time, there is not. Here is why:
When clinics bill health insurance companies directly, the doctors are required to become participating providers. The doctor must sign a contract that allows the insurance company to determine which services they will and will not provide and how much they can charge for those services. In general, insurance companies are not focused on any preventative, wellness, or travel-related services. They are heavily invested in cost containment and providing only the bare minimum that might be required by law. We are committed to treating you with only your best interests at heart.
A participating provider must agree to accept the fees the insurance company establishes, regardless of whether the fees are reasonable or applicable to that practice. In general, these established fees cover the actual cost of the briefest (and we believe the lowest quality) care. Doctors who are participating providers are required to accept discounted fees for their services, and they cannot bill the patient for the difference between their fee and what the insurance company will pay. Therefore, the clinic must write off the difference, often as much as 50% or more of the doctor’s fee for service. At the same time, participating providers’ office overhead costs have increased dramatically because of the staff, time, and equipment necessary for processing and tracking claims.
In today’s healthcare environment, the actual cost for doctors to provide services continues to rise, while the percentage of reasonable fees that insurance payments cover is declining. At the same time, the profits of health insurance companies and the salaries of their top executives continue to rise to record levels.
Most doctors and clinics cope with the requirements of being participating providers by keeping their office visits very brief, so that they can see many patients within a given time frame. When their clinic becomes unprofitable, it must be supported by another institution. Most primary care medical clinics are not self-sustaining financially and have had to merge with hospitals whose expensive, high-tech surgical and diagnostic procedures are priced to keep the clinics afloat financially. Ironically, some of our patients complain about their extremely brief and unsatisfactory office visits in other urgent care and medical practices, while at the same time expressing frustration that we do not accept insurance. Unfortunately, we have found that we cannot be participating providers in the insurance networks and provide the time-intensive, expert care that we do. Avoiding the time spent arguing with insurance companies also frees up our staff to be available to talk to you on the phone when you call, answer your emails in a timely manner, and call specialists directly to expedite getting a referral appointment the same day or providing you with whatever service is above and beyond what you would expect from a doctor’s office.
Why Our Doctors Must Charge for Your Follow-up Consultations
Some patients have asked why we charge for follow-up consultations if one is necessary. Our goal is to diagnose and treat you effectively on your first visit. There are times when a disease or symptom evolves and we are not able to make a diagnosis or treatment plan without continuing to examine and see that evolution first hand (i.e., influenza that later becomes complicated by pneumonia). Many situations cannot be safely handled over the phone or via email. Our doctors are not salaried, as are doctors who are employed in large clinics and hospitals and whose salaries are partially subsidized by expensive diagnostic and surgical procedures and hospital fees. Our doctors’ pay is based solely on the time and services they provide. Like all non-salaried professionals, including lawyers and accountants, our doctors must charge for their time so we can afford to provide you with care and remain in business. In general, we charge only for our face-to-face time with you. Our doctors spend considerable non-reimbursed time each week consulting with each other (and other providers) regarding your care, reviewing your records and lab results, and communicating with you outside of the office.