Billing and Insurance

Presented by: Revenue Cycle Department

August 7th 2013

Objectives

Present an overview of insurance and the billing process

Answer some of the questions most frequently asked by our patients

Let you know about the resources Summit Medical Group has available to assist you with your billing concerns

Accurate Billing Starts with your Insurance Card

• Wrong insurance information delays processing of claims and leads to billing errors which can be reflected in your statement.

• Bring all your current insurance cards to every visit.

• Notify us when you have a change in insurance, address, or phone number.

http://summitmedicalgroup.magnify.net/video/News-and-Happenings-Insurance-C;recent

Insurance Cards Video

Participating Insurance Plans• Aetna • Aetna Medicare • Amerihealth• Anthem BCBS• CHN• Cigna• Coventry (First Health)• Empire BCBS• Great West

• Horizon • Horizon Medicare• Magnacare• Medicare (Traditional)• Railroad Medicare• Oxford Freedom• PHCS/Multiplan • Qualcare

• United Healthcare

Medicare

• Traditional Plans

• Medicare Advantage Plans Aetna Medicare Horizon Medicare Blue

Non-Participating Plans

• Oxford Liberty

• GHI/Emblem Health

• All Other Medicare Advantage Plans

….but there are always exceptions!

• Oxford Liberty participating at some locations.

• GHI/Emblem Health participating when the Qualcare logo is on the front of the card.

• United and Oxford Medicare Advantage plans participating at some locations.

Look for insurance information on the Summit Medical Group website

http://www.summitmedicalgroup.com/ Summit Medical Group website

Intention of the Visit

Summit Medical Group providers do not code your visit according to your benefits.

The provider codes according to what was done during the visit.

In addition to the physical or office visit you may be billed for lab work, x-rays, and other diagnostic testing

How a Service is Coded

You scheduled a routine colonoscopy• Screening – no family history, no symptoms• When billed as a screening there is no cost

sharing to the patient• During the procedure a polyp is detected and

removed.• The diagnosis changes from routine to diagnostic• Cost sharing now applies

Know Your Benefits

Always check with your insurance carrier to confirm your benefit coverage

A Few Questions to Ask

• Is my provider participating in this plan?• Am I required to select a PCP, Primary Care

Provider?• Does my plan require referrals?• Is this a covered benefit under my plan?• What will my cost sharing be?

What is Cost Sharing?

Cost sharing is the patient balance that remains after the insurance plan has applied payment for covered services according to your benefit plan.

It is the amount you are expected to pay.

What does it include?

Cost Sharing includes:

• Copay• Deductible• Coinsurance

COPAY• A fixed amount you pay

for a covered health care service , to be paid when you receive the service

• The amount can vary by the type of covered health care service.

• $15 primary care• $25 specialist

Primary Care Visit

Allowed Amount $100.00

Insurance Pays $ 85.00

Patient Copay $ 15.00

Specialist Visit

Allowed Amount $100.00

Insurance Pays $ 75.00

Patient Copay $ 25.00

Deductible

• The amount the patient owes for healthcare services before your health insurance plan begins to pay

• Deductible may not apply to all services

• Deductibles are applied annually

Plan Deductible $1000.00

Your plan won’t pay anything until you’ve met your $1000.00 deductible for health care services subject to the deductible

Coinsurance

Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for the service

Co-insurance plus deductible may apply in some cases

Allowed Amount $100.00

20% Co-insurance $ 20.00

Insurance Pays $ 80.00

Allowed Amount $100.00

Deductible $ 20.00

20% Co-insurance $ 16.00

Insurance Pays $ 64.00

Cost Sharing Tools

Most commercial Health Insurance carriers have cost estimators on their websites to help you estimate your out-of-pocket expense.

• Calculate your estimated costs for procedures, office visits, lab tests, and surgeries.

• Compare what your cost sharing will be at different providers and locations.

Medicare Cost Comparison

Medicare also provides transparency into healthcare costs on their website

• You can compare hospital pricing for hospital inpatient and outpatient care

• The annual Medicare and You booklet also provides insight into Medicare covered benefits

Visit the Medicare website: www.medicare.gov

Your Billing Statement

• Statements go out every 35 days• You will receive a statement when your balance is

$10 or greater. • Summit Medical Group bills patients according to the

Explanation of Benefits (EOB) that we receive from your insurance carrier.

• Match your EOB to the Summit Medical Group statement to verify that you have been accurately billed.

Explanation of Benefitshttp://summitmedicalgroup.magnify.net/video/News-and-Happenings-Understandi;recentUnderstanding EOB video

How to Read your Statement

How are my Payments Applied

The copays you pay at the time of service are applied to that date of service.

In some cases your copay may be applied to an outstanding balance for a different date of service.

This is done to prevent older balances from aging and going to collections.

Convenient Ways to Make a Payment• Mail a check to the payment address on your

statement. Sorry no credit cards by mail.• Call Patient Accounts at 908-790-6500• Make a payment at your next visit to any

SMG location• Make a payment on-line at

http://www.summitmedicalgroup.com/

Summit Medical Group website

Pre-Collection Process

• You will receive 3 statements before balances are flagged at collect status

• Statement messages indicate the aging of your statement balance

Statement Messages

Second Statement:• Your account is overdue; please pay this

balance immediately.

Third Statement:• Your account is in collections status; please

contact the office immediately.

Collection Letters

You will receive a separate letter from Summit Medical Group when your balance is billed on a second and third statement.

The letter is to remind you that your account is in collect status and if the balance is not paid it will go to our outside collection agency.

Collection Policy• Summit Medical Group does send aged balances to

a collection agency.

• Summit Medical Group has contracted with Simons Collection Agency to help us recover unpaid patient balances.

• Account balances are sent to the collection agency after you receive 3 statements and you do not make a payment.

What to Expect from the Collection Agency

• Patient receives automated and live calls from the agency.

• Collection balance is not reported to the credit bureau until 90 days after placement with the agency.

• Payments can be made directly to Simons or to Summit Medical Group.

• Simons will update Summit Medical Group records to show your payment was made and clear your balance.

We are here to help

• Assist you in Understanding your statements• Offer payment plan options• Provide Financial Counseling• Summit Medical Group is a billing resource

for our patients; however, your Insurance Plan is and should be the first resource for questions about your benefits.

Patient Accounts Department

• Patient account specialists are available to answer your questions and take your payments over the phone Monday – Friday

• 9:30 a.m. to 4:30 p.m• Phone number: 908-790-6500• Billing e-mail: billings@smgnj.com

Financial Counselors

• Located at 1 Diamond Hill Road, Berkeley Heights in the Lawrence Pavilion.

• 150 Floral Avenue, New Providence• Appointments can be made for on-site visits. • Walk-ins are also welcome.• Annette Austion-Brown 908-790-6596• Courtney Parker 908-273-8896• William Stratton 908-273-8957

Thank you

Questions

Participating Plans

• Although we participate with these plans benefits vary depending the group package – Use Oxford Liberty as an example

• Some services may be considered non-covered services based on your individual plan

• Check with your insurance carrier for confirmation of benefits and cost sharing

• Information received is not a guarantee of payment

HMO

• Most HMO plans require you to select a Primary Care Provider – PCP

• Primary Care Provider is a doctor whose specialty is Internal Medicine, Family Medicine, or Pediatrics

• Patients can select their PCP or change their PCP by calling the health plan.

• Some HMO plans do not have out-of-network benefits.

Referrals

• Some plans may require a referral from your PCP to a specialist or facility

• Summit Medical Group will get the referral for our patients who have selected an SMG provider as their PCP

• Patients who have selected a PCP outside SMG must get a referral from their PCP

Authorizations

• Some services such as Imaging or Surgery may require prior-authorization under the terms of your health insurance plan

• Summit Medical Group will obtain the authorization for procedures ordered by our providers as required by your plan

Medicare

There are two main ways to get your Medicare coverage

• Traditional Medicare• Commercial Medicare Advantage plans

Decide how to get your Medicare Coverage

Traditional Medicare includes:• Hospital Insurance (Part A)• Medical Insurance (Part B)

You will need a separate plan for your Part D, Prescription Drug Coverage

Medicare Advantage Plan:

• Combines Part A, Part B and usually Part D

Understanding Benefits Cont’d• In addition to the physical or office visit you

may be billed for , lab work, x-rays and other diagnostic testing, procedures

• Your insurance carrier may apply co-insurance and deductible to some of these procedures in addition to your co-pay for the visit

• Authorizations; Waivers and ABNs