Insurance and Billing
Insurance Information: Your Records
Please note:
Our facility participates with both Highmark and UPMC insurance companies as well as most other insurance companies..
Please be sure to bring your current insurance cards and a photo ID with you to each visit. We will need to keep current copies in your records.
We accept most insurance plans. Most insurance plans and managed care payers have policies that require co-payment at the time of service. You will be responsible for payment of all co-pays and any outstanding balances at the time of visit. If you are covered under an HMO or other managed care plan (Point of Service or PPO) there may be specific coverage limitations. If services are not covered under your insurance plan you are responsible for payment. You will be required to pay for such services at the time of the visit.
Your Healthcare Benefits: Insurance Coverage
If there is any question about our participation with your insurance, please contact our office with your insurance information. We will do our best to help you interpret your healthcare benefits and coverage requirements. However, it is your responsibility to understand which services are covered and which are not covered under your plan and if both our physicians and our outpatient facility participate with your insurance. Likewise, it is your responsibility to identify any coverage changes that may be initiated by your employer or managed care plan. If you have any specific questions, we encourage you to contact your insurance company prior to your appointment. Our billing will include doctors professional fees as well as outpatient surgical facility fees.
If you have difficulties understanding or paying for our services, we encourage you to discuss your problem with our billing office staff.
Please see the insurance and billing policy information below and contact our office if you have any questions.
As a courtesy to you we will bill your insurance carrier if you provide us with complete insurance information. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. If your insurance company has not paid your account within 30 days, the balance will be assessed to you for payment. You should remit payment within 30 days or contact your insurance company to check the status of the claim. Please notify us immediately upon contacting your insurance company or if there is anything we can do to help settle this claim.
Your Payments: Billing Procedures
We will bill your insurance carrier for you.
You will be asked on your appointment date to pay for services not covered by insurance. This includes deductibles, co-pays, and co-insurance amounts, occasionally office visits and cosmetic procedures. We accept cash, check or credit cards.
Some insurance plans apply separate co-pays for both the office and the outpatient facility. You will be responsible for both.
After 30 days, if insurance has not processed the claim, it will become your responsibility.
More Insurance Information
We are NOT participating with medical assistance programs. These include, but are not limited to: Gateway, MedPlus, UPMC for You, and Unison. In situations where this may be your 2nd insurance, you are responsible for any balance due that is not covered by your primary insurance carrier.
Medicare:
Medicare patients are responsible for paying their annual deductible each year and are responsible for the 20% allowable charges not paid by Medicare thereafter. If you have 2nd coverage, we will also bill this insurance for you. If after 60 days, the 2nd insurance carrier does not cover this portion of the bill, our office will bill you directly.
Some highmark products require a home host waiver. These policies usually apply to patients who are employees or the spouse of an employee of a medical facility. This means that because the employees facility does not offer a particular service (Mohs surgery), a special waiver must be obtained for you to seek treatment at another medical facility. As a provider, we cannot obtain this waiver, it MUST be initiated by the subscriber. You will need to contact your benefits administrator. Let them know that you require a home host waiver. This process takes several days. It is your responsibility to notify our office once you have received approval. Without this approval your surgery will need to be rescheduled.
If prior authorization or referral is required, please contact your insurance company or your primary care physician at least one week prior to your appointment. Let them know the following:
You are having Mohs Surgery and possible reconstruction, this will be performed in an outpatient Ambulatory Surgical Facility.
Procedure code 17311
Diagnosis code 173.91
Many patients and physicians alike have asked about the facility co-pay that some of our patients are charged for our services. As a licensed Surgery center, we are required to bill for both the physician fee and a facility fee. In return, the insurance company reduces the amount of payment to our physicians. Patients with traditional Medicare will not have a facility co-pay, but some other insurance companies have instituted a co-pay of various amounts depending on their plan, just as they have increased deductibles and co-pays in general.
We feel that the high standards associated with the Ambulatory Surgery Center improve patient care. While the value of each of the following advantages may seem small, the combination of every one becomes significant to insure quality and safety for all patients. These are some of the features of our Ambulatory Surgery Center that differ from most office settings for surgery.
1) Fewer errors: There are strict policies and procedures to insure oversight for all aspects of patient care to prevent wrong site surgeries, missed biopsy and laboratory reports, and missed patient follow-up visits for serious disease. If there are significant events, they are logged, reported to state agencies and policies and procedures evaluated and changed if necessary.
2) Fewer complications: We closely monitor complications, measure quality, set goals and work within benchmarks to keep post-operative bleeding and infection rates below nationwide practice standards.
3) Highly trained staff: Policies and regulations insure that our staff is properly licensed, trained and credentialed to perform all their duties. Continuing education is provided and enforced to meet or exceed all requirements.
4) Patient privacy and security: Maintenance of licensure and site visits from accrediting organizations insure that all HIPAA standards are met and monitored for patient privacy.
5) Rights of Patients: We distribute and display a code of Patient Rights, and preserve confidentiality. We adhere to and are monitored by accrediting organizations for truth in marketing, advertising and web content to prevent any misleading claims. We have a grievance policy for patients.
6) We continuously work on improving quality. We have an active Quality Improvement system that works to measure, investigate and continuously improve quality in all areas including peer review, risk management, protection of patients and staff. We measure patient satisfaction and make plans to improve and impletment corrective action to resolve problems that may by identified. We review records regularly to insure accurate and timely recording of patient encounters.
7) We innovate treatments, educate and train young doctors, set examples continuing education, perform research that continues to allow us to provide cutting edge treatment, add to the fund of knowledge of our specialty, and provide leadership in national organizations.
8) We are licensed, monitored, and site visited by multiple organizations each year including
a. CMS Medicare
b. Pennsylvania Department of Health
c. Pennsylvania Department of Safety
d. Accreditation Association for Ambulatory Health Care
e. Accreditation Coucil for Graduate Medical Education
f. Clinical Laboratory improvement Amendments CLIA
g. Occupational Safety and Health Organization OSHA
These organizations perform routine inspections of the Facility, often unannounced, and review all policies, procedures, monitor adherence to regulations for patient rights, governance, administration, quality of care, quality management and improvement, clinical records, infection prevention, facilities and environment, surgical and anesthesia service, pharmaceutical services, pathology and laboratory services, teaching and research activities, fire safety and employee safety. The requirements are detailed and require a high level of daily maintenance. Altogether, it reduces errors, and maintains the highest quality of patient care. The additional co-pay that some patients are charged is required by their insurance company is balanced by the layers of attention paid to details of delivering all of their care.
We hope that this information assures you that the added value of our licensed Ambulatory Surgery Center is worth the co-payment that your insurance company requires.
