If you visit a dentist within your insurance company`s network, their office will bill your insurance company directly for all services provided. Upon receipt of the claim, your insurance will cover the cost of treatment based on the eligible price of your plan and the contract rate they have with the dentist. In many cases, it`s more cost-effective than a visit to an unaccompanied dental practice and certainly cheaper than paying out of pocket. For most prevention and diagnostic services, your liability is minimal, if at all. It`s important to note that even if your insurance company treats your off-grid care as if it were on the network, federal law does not require the off-grid provider to accept payment from your insurance company as full payment. Knowing how to bill non-accredited and non-contract suppliers can help you ensure your service requests are accurate and help you avoid regulatory errors that could lead to audits and, even worse, fines. It can be difficult to understand how to bill and receive payment for a clinician (physician or intermediate level) who is new to your emergency practice, but is not accredited or under contract with the health plans in which you participate. In some cases, however, the insurer prefers to keep the network relatively small so that it has a stronger basis for negotiation with suppliers. If this is the case, your doctor may be willing to join the network, but the insurer does not have network openings for the services offered by your doctor. As a medical biller in a doctor`s office, you may face litigation involving an unaccompanied payer. This can be a confusing term to understand. Most health care providers file claims with non-contractual payers to ensure patient satisfaction. Some doctors` offices will ask patients whose payers are not contractual to pay the full amount at the time of service, or will ask the patient to pay only the patient`s expected share at the time of service and allocate the remaining payment to the provider.
We ask you to provide a copy of your health insurance card at the time of service so that we can set up the correct billing information. Finding a suitable insurance plan that fits your budget while providing you with the benefits you need can be a daunting task. Making sure your dentist is engaged under this plan is just as important. As this is an important consideration for many patients, we want to help you understand the role your insurance benefits play in each scenario. There`s a lot of confusion when it comes to insurance benefits, contract and non-contract dentists, and what those things actually mean to you as a patient. Non-contract dentists are dentists who can accept or submit your insurance claims, whether or not they are outside the network. If a dentist is outside the network or is not under contract, it means that you are responsible for your percentage of the dentist`s actual fees. (Example: Dr.
Anderson charges $100 for a fill and your insurance company pays 80%, you, as a patient, would pay $20 and your insurance company will reimburse Dr. Anderson $80).) Sometimes patients have been going to the same dentist for many years, but suppose he/she decided to give up your insurance at the beginning of the coming year, how will this affect you? Some patients are not afraid to spend a little more money to know the environment and comfort level not only with the dentist, but also with the office staff, and then there are certain situations where patients have to save money wherever they can, so when the dentist changes, he also has to change. Everyone`s situation is different, so it`s up to the patient to decide which is the best option for them. Some insurance plans that do not allow payment for providers outside the network may process the claim to place the entire amount charged under the responsibility of the patient, or they may pay the claim without deducting a discount. Please contact your insurance company directly if you have specific questions about your insurance plan or coverage. For example, suppose your insurance company has a “reasonable and usual” rate of $500 for a particular procedure and you have already reached your deductible on the network. Then you find yourself in a situation where an off-grid provider performs the procedure, but this is one of the scenarios described above and your insurer agrees to pay the $500. But if the off-grid provider charges $800, they can still send you an invoice for the remaining $300. Mutual billing is another option for urgent processing when replacement agreements are not available or are no longer an option. Like replacements, mutual billing agreements cannot last more than 60 days.
These transitional measures are supposed to be a temporary solution, and Medicare expects your clinic to work to hire regular certified and contract physicians to provide services. If The Doctors Clinic is not under contract with your insurance company, we will always charge your health insurance as a courtesy to you. All balances are considered the patient`s responsibility, regardless of whether your insurance company has paid or not. Full payment is due within thirty (30) days of the date of the first settlement, unless prior payment agreements have been entered into. Doctors Clinic accepts cash, debits, personal checks, VISA, Mastercard and Discover. Please understand that even if you expect the insurance to cover all or part of your medical treatment, you are responsible for your bill. It is advisable to familiarize yourself with your insurance benefits. Your health plan states that you are financially responsible for paying all co-payments, deductibles and services not covered, and the Doctors Clinic – part of the Franciscan Medical Group – is contractually obligated to recover them. Please do not ask us to adjust them from your account. In these situations, practices often use an unlicensed or non-contractual provider and ask their billing company if they can “bill the new provider under the name of the clinic or under the name of another physician.” A network provider is a doctor or hospital that has signed a contract with your insurance company and agrees to accept the insurer`s discounted rates. For example, the doctor may charge $160 for an office visit, but they have agreed to accept $120 as full payment if a patient is treated with XYZ insurance (and they may have agreed to accept $110 as full payment if a patient has ABC insurance). Therefore, if the patient has a co-payment of $30, the insurer pays $90 and the physician writes off the remaining $40 because it is higher than the rate negotiated by the network (i.e.
the initial fee of $160, which has been reduced by $40 to reduce it to the rate of $120 negotiated by the network; this amount is then shared between the patient and his insurance company, where the patient pays the co-payment of $30 and the insurance plan pays the other $90). Non-contractually bound payers are physicians (also known as healthcare providers) with whom the provider does not have a contract. It`s also important to note that credentials to become a networked provider are not an easy task. Each insurance company has its own requirements for a dentist to become a networked provider. Dentists who go through this process show determination and attention to detail, characteristics that they also apply to your care. There are many different insurance companies and each dental plan is designed specifically for you and your group, so their benefits will most likely be different unless two people work for the exact same company and have exactly the same group number. If you have any questions about your benefits, please contact Lacie at 816-454-3336. Check with your contract health plans to make sure you`re adhering to your mutual billing and billing policies. Again, if you don`t know what is required of a particular payer, it`s a good rule of thumb to follow Medicare policy.
Alternative medical services may be billed under the missing doctor`s NPI, with the Q6 (Alternate Physician Service) modifier added to each CPT code on the claim. If the substitute physician provides postoperative services during the overall period, the alternative services do not have to be indicated on the application. Practices must keep a record of patients seen by the locum physician (including the replacement`s NPI), and this list should be made available to commercial insurance companies if necessary. What does it mean to be a contract dentist? If a dentist is hired by your insurance company or is part of the network, your dentist has worked closely with the insurance company to develop a reduced fee that is lower than the full fee or the price of the office sticker, if you will, making the patient`s liability lower than if you went to a dentist. that was outside the network or was not contractually bound. .