Payment, Billing, & Insurance
When you visit Nanopractice PDX you have several payment options: you can pay in cash at the time of service (check or credit card accepted) or your insurance can be billed. See below for a list of accepted insurance companies. (add paypal button?)
Insurance: If your insurance is on the list, Nanopractice PDX will bill your insurance for each visit and you will be responsible for any portion not covered by your health plan (i.e., your co-payment, co-insurance, or deductible) – just like you would at any doctor’s office. The exact amount that you will owe depends on the rules of the specific health insurance plan you have. See below for a general primer on health insurance.
Out of Pocket: If you choose to pay for your visit out of pocket, payment is expected at the time of service unless prior arrangements have been made. As a gesture of consideration, Dr. Chrissie offers a whopping 40% discount for payment at time of service (this is quite a bit higher than the industry standard). If you are paying out of pocket but need to extend your payments, the 40% discount decreases to 20% and this should be arranged prior to your visit. A new patient visit would then be on the order of $200 and follow up visits around $100 depending on the length and type of visit.
For some types of insurance, it may be more advantageous to pay out of pocket and submit a receipt for reimbursement. This can be especially helpful for people with high deductibles or HSAs (see below).
How billing works
- After receiving payment from you or your insurance company your account is credited. If there is a balance, you will receive a Nanopractice PDX billing statement at the beginning of the following month.
- Payment of that balance is due upon receipt and can be paid by check, cash, credit card, or Paypal. (again, link to button?)
- If you have not paid by the following month you will receive a second statement.
- If a third statement is required, the account will begin accruing a $20 late fee monthly.
- After good faith attempts are exhausted and 120 days have passed, your account may be referred to a collections agency. This is a highly unlikely and deeply undesired situation.
- On rare occasions after an insurance company has paid a claim, they have reason to reverse payment. One example is when insurance lapses and is retroactively voided. The patient is immediately liable for the reversed payment amount in this case.
The health insurance process can be complex and confusing. Here is some basic information to help you better navigate the increasingly complex insurance system.
How health insurance works
Health insurance companies generally profit by assuming the risk inherent in healthcare. They are basically betting that you as an individual will use fewer healthcare dollars over the course of your contract with them than you and/or your employer pay them to assume this risk of coverage. If you are healthy and not a frequent healthcare consumer with pricey coverage, then they’re right and they profit or use this “win” to offset your neighbor who had relatively inexpensive coverage but used $100,000 this year in healthcare dollars due to an extended ICU stay. So, it’s in the insurance company’s best interest to keep you well and far away from the ER or other less efficient, more costly care delivery systems. They also protect their investment by limiting coverage of expensive medications, procedures, labs, and sometimes even vaccinations. They negotiate contracts with individual practices to get discounted rates for services provided to their flock of insured people.
Many people with health insurance receive it through their employer, others purchase individual policies. In recent years, premium costs for insurance, as well as out-of-pocket costs for deductibles and co-payments have skyrocketed for employers and employees as well as the self-insured. The total increase in healthcare spending has led to the current national debate on cost control and increasing access for the uninsured. If you have not seen the movie “Sicko”, it’s worth the time. Though the system is undeniably in need of reform, here are some key points to remember:
Nanopractice PDX and similarly streamlined “ideal micro practices” are pioneering a more efficient and more satisfying way to care for your health.
Since health insurance companies only pay for direct office visits, the small annual membership fee helps to cover the costs of providing online/email services that you won’t find in many other medical practices.
Insurance companies have created many rules to try to keep costs down. Though these rules may sometimes be beneficial, it is impossible to keep track of all of them. Every plan has different rules, and there are hundreds of health plans. Because of this, I ask that you try to learn more about your own insurance plan and what is covered/not covered. This is best done by calling the number on your insurance card or reviewing your policy.
This is the amount that you are required to pay before your insurance “kicks in”. This number is trending upward as employers are less able to pay for health care costs. Your annual deductible may range from $200 to $2000, for example, and the small print in your policy may indicate a separate deductible for procedures in addition to your deductible for office visits.
This is the amount that you pay when you come in for a visit.
As a PPO patient, it’s a form of pre-payment. For example, let’s say you came in for a visit that cost $200. Your co-pay was $20. And after submitting a claim to your PPO insurance company, we are paid $100 by your insurance company. The remaining balance ($80) may be written off in part or in full depending on the insurance contract, or some of that may be passed on to you as a balance if you also owe a portion of your deductible or if you have a co-insurance payment.
Some health plans are structured so that you pay a percent of your health care bill, often ranging from 10-50%. Similar to a deductible, this amount is pre-specified by your individual health plan. Some plans include a co-insurance payment but no co-pay up front. In this case, you will receive an EOB (see below).
EOB (Explanation of Benefit) Statement
This is the statement from your insurance company detailing how much your insurance paid and how much you owe Nanopractice PDX for your visit. Feel free to send this amount (minus your co-pay) as soon as your EOB arrives. Otherwise, billing statements are emailed at the beginning of each month and payment is due upon receipt.
PPO (Preferred Provider Organization)
This type of insurance gives you some flexibility in provider selection, but it may be more costly than other options. Deductibles, co-insurance, and co-pays are common. In addition, some PPOs have increasing restrictions on which medications they are willing to cover. A preferred provider has signed a contract to accept a discounted rate of payment for their services, so the difference between the negotiated rate and the provider’s fee is “written off” by the provider. As a PPO member, the insured person is only responsible for the negotiated rate for a given service even if it is applied to their annual deductible. Furthermore, the co-insurance is calculated as a percentage of the negotiated rate, not the provider’s actual fee.
HMO (Health Maintenance Organization)
This form of insurance offers comprehensive coverage among a more limited selection of providers. Visits to specialists often require referrals, and diagnostic tests, procedures, and specific medications may require pre-approval or prior authorization. Out-of-pocket costs are generally lower than other forms of insurance, but monthly premiums are usually higher. In addition, this form of insurance often includes a “capitated fee” meaning that a provider is paid monthly for all the HMO members in his or her practice but is not paid extra for their office visits. Dr. Chrissie does not participate in any HMO plans.
POS (Point of Service)
A POS insurance plan is a combination of PPO and HMO. You have the flexibility of both HMO and PPO coverage, but are charged depending on who you see (preferred vs in-network vs. out of network with increasing cost). These plans are functionally quite similar to PPOs but can sometimes be a little cheaper.
HSA (Health Savings Account)
This is a relatively new form of “insurance” that’s becoming more and more popular across the country. It essentially moves the full burden of costs to the patient. If you don’t spend any money on health care, you get to save the money in a special tax-free account. If you do utilize health care services, you pay the full cost yourself with pre-tax dollars. Essentially, you become the risk taker instead of paying the insurance company to take the risk. It is financially advantageous if you utilize less health care than your insurance premium would cost you. It is always advisable to carry catastrophic insurance in addition, as even the healthiest among us can find ourselves in surprising situations.
For more definitions: http://www.insurelane.com/health/glossary.html
* Thanks to Metropolitan Medical Group of San Francisco for some of the copy regarding insurance info!