This web page is designed to inform you about how various forms of health insurance work and how they interact with our office. We would like to inform you and establish a good rapport with you regarding your account from the very first day you come in our doors. Our people want to help you with your insurance, but it is becoming extremely complicated and this is why we thought it would be wise to write this pamphlet. As you read through it, please keep in mind that we are here to help you and if there are ever any questions, please do not hesitate to ask.
I. Third Party Insurance
One of the first concepts that we would like to promote is that you must give ALL your insurance information to the staff. Remember that many procedures may be covered under medical insurance as well as dental insurance and it is wise to give both medical and dental insurance to the staff when you first come in so that we can be reviewing it for you as you have your consultations. Remember that it is also your responsibility to bring us the forms that we will need to submit your third party insurance.
A. Deposits
You will note that when you have your financial consult that you will be asked to put 25% down on the work that is being undertaken at the time of service. This is because most third party insurances pay 75% to 80% of what they establish to be an acceptable fee. This does not mean that they are going to be paying ~our fee. We hope to calculate this so that after your insurance finally does pay, you will not have much of a balance, but frequently you will still have an outstanding balance and you will be responsible for it. You must remember at all times, that you are responsible alone for your bill. Your insurance company that you hire and purchase insurance from is there to assist you in this, but ultimately you are responsible for its activities as well as the ultimate payment of your bill. This means that you are responsible for making the telephone calls and seeing that your insurance company pays as it should.
B. Deductibles
It is very important that you read your statements when they are mailed to you monthly You may see that there is a phrase that says some number of dollars has been “applied to your deductible”. This means that you haven’t had a chance to meet your deductible for that year and that you will have a higher outstanding balance with us because of the policies of your insurance. This balance must be paid by you and not by the insurance.
C. Non-Covered Services
Your insurance company contracts with you to provide certain basic services. However, exactly what services these are is a negotiated agreement between your insurance company and your employer. If your employer decides that they do not want to cover certain types of care, that is completely up to them. This means that frequently a health insurance will delete certain classes of procedures or certain areas of the body from care. This means that you will become completely responsible for these procedures if you ever have to have them done and this is noted on your statement as a “Non-covered Service”.
D. UCR = Usual and Customary Rate
This is an insurance aphorism which means that the insurance company has decided how much it is appropriate to pay a doctor for a certain procedure. This does not take into account our office fees and costs. Our charge may be higher or lower than this UCR. In most cases, insurances will pay 8O% of their usual and customary fee which leaves you the outstanding balance of the remaining 20% of the UCR PLUS whatever the difference is between our fee and the UCR. If our fee is higher you will have a higher outstanding bill. If our fee is lower, you will be responsible for whatever the remainder balance is.
E. Confused Claims
In the case of confused claims or where insurances make mistakes or request more information, it is frequently necessary to “resubmit” an insurance. i.e. put the claim in a second time for the same work. Our office will take care of doing this for you, but you must understand that it takes time and in the meantime you will be responsible for the timely payment of your balance. Do not let your insurance get you into collection difficulties because of their inefficiency. In the case of multiple insurances, we have to submit to one insurance before we can submit to another insurance. We will take care of this automatically for you, but there again, remember that this takes time. Another point of confusion is when the insurance asks the patient “for more information”, do not ignore this note and please provide this to the company as quickly as possible.
F. Refunds
There are times when the insurance payment that we receive is higher than expected and this means if you have put your 25% down, you may actually have a credit coming back to you. Refunds are processed at Androscoggin Oral & Maxillofacial Surgeons, PA. once every month. You will receive your refund in the mail. Refunds may not be picked up in person.
G. Pre-Authorizations
There are certain procedures which insurance companies do not understand very well so the procedure codes are automatically flagged and the doctor has to submit why he wants to do these procedures to the insurance company. The insurance company will then decide whether or not they will pay for them.
This process is called Pre-Authorization. Our staff is experienced in knowing which codes require these pre-authorizations and we will take care of this for you, but please be advised that if you are told a pre-authorization must occur for the procedure to be paid for, it may be a while before you can have your procedure performed.
H. Contractual Changes
Your insurance company is fighting desperately in its market place for survival. This means that they will change their policies and contracts at will with very little or no notice to you or to your employer. The other possibility is that they may inform the employer and your employer may be slow in informing you. What this means is that it can appear to you that a procedure may be covered one month, and then one month later it will not be covered. Please understand that we have absolutely no control over this and please have patience with us. Our staff does not like to be the bearer of bad news, but frequently we have to be. This is frequent in the areas of orthognathic surgery and temporomandibular joint in the managed care era. To add to the conflict, your insurance company may not want to admit to you that they are not going to cover you and will refer you back to us. We are not their agent. It is up to you to clarify this.
I. Communicating With Your Insurance Company
We encourage you to communicate with your insurance company frequently. This will aid you with the above paragraph, but also it educates you as to the quality of the insurance that you are paying for. If you are having a difficult time dealing with your insurance company, then you can appreciate that you are not getting good service. You might want to consider that the next time you have an opportunity to change insurance plans or you may want to consider obtaining other insurance. The purchasing power of the dollars that you have put into health insurance is tremendously strong, but unfortunately many people in the United States do not understand how to intelligently select an insurance. Simply the cheapest insurance at the time may not be the one that best suits your family. You are wise to think about your needs before speaking with your employer about it. If you ever do have to communicate with your insurance, we strongly suggest that you get a, first and last name of whoever you talk to there and that you save all Explanation of Benefits, letters, telephone messages etc. You may also find that when you deal with your insurance company that the insurance company simply does not know the answers to your questions. This is because many insurance companies hire many people who are not educated enough for their job and do not understand the insurance anymore than you do. Be patient and perhaps our staff can also help you in this regard.
II. HMOs – “Health Maintenance Organization”
Health Maintenance Organizations are becoming much more popular as they are a much more cost effective way of delivering health care for an employer. HMOs would not exist if it were not for an employer’s desire to cut costs for their respective companies. It is difficult to describe how an HMO is different from a third party insurance without referring to specific HMOs but suffice to say their entire structure of organization is different, their policies are radically different, and they are regulated by an entirely different set of state regulations.
A. “Gatekeepers”
Frequently HMOs require your family doctor, i.e. physician, to be the “gatekeeper” of services that you require. This means that he has to approve any procedure that is performed and frequently many diagnostic tests, i.e. any referrals to any surgeons, any referrals for any large dollar diagnostic items such as MRI’s, CT, etc., and any lab work. It is your responsibility to know if your appearance in this office requires the permission of your gatekeeper and to get that gatekeeper’s referral. To make it easier for you, many gatekeepers fax us their referral slips so if you have forgotten to do it, we should still be able to get it quickly. Remember, if we do not have it, you will be responsible for our fees in full at the time of your service.
B. Co-Pays
Many HMOs require the patient to pay a small co-pay of usually $5.00 to $30.00 at the time of service. Our staff will be collecting this from you and it will appear on your statement that it has been collected.
C. Non-Covered Services
Your insurance company contracts with you to provide certain basic services. However, exactly what services these are is a negotiated agreement between your insurance company and your employer. If your employer decides that they do not want to cover certain types of care, that is completely up to them. This means that frequently a health insurance will delete certain classes of procedures or certain areas of the body from care. This means that you will become completely responsible for these procedures if you ever have to have them done and this is noted on your statement as a “Non-Covered Service”.
D. Pre-Authorizations
There are certain procedures which insurance companies do not understand very well so the procedure codes are automatically flagged and the doctor has to submit why he wants to do these procedures to the insurance company. The insurance company will then decide whether or not they will pay for them. This process is called Pre-Authorization. Our staff is experienced in knowing which codes require these pre-authorizations and we will take care of this for you, but please be advised that if you are told a pre-authorization must occur for the procedure to be paid for, it may be awhile before you can have your procedure performed.
E. Contractual Changes
Your insurance company is fighting desperately in its market place for survival. This means that they will change their policies and contracts at will with very little or no notice to you or to your employer. The other possibility is that they may inform the employer and your employer may be slow in informing you. What this means is that it can appear to you that a procedure may be covered one month, and then one month later it will not be covered.
Please understand that we have absolutely no control over this and please have patience with us. Our staff does not like to be the bearer of bad news, but frequently we have to be. This is frequent in the areas of orthognathic surgery and temporomandibular joint in the managed care era. To add to the conflict, your insurance company may not want to admit to you that they are not going to cover you and will refer you back to us. We are not their agent. It is up to you to clarify this.
F. Communicating With Your Insurance Company
We encourage you to communicate with your insurance company frequently. This will aid you with the above paragraph, but also it educates you as to the quality of the insurance that you are paying for. If you are having a difficult time dealing with your insurance company, then you can appreciate that you are not getting good service. You might want to consider that the next time you have an opportunity to change insurance plans or you may want to consider obtaining other insurance. The purchasing power of the dollars that you have put into health insurance is tremendously strong, but unfortunately many people in the United States do not understand how to intelligently select an insurance. Simply the cheapest insurance at the time may not be the one that best suits your family. You are wise to think about your needs before speaking with your employer about it. If you ever do have to communicate with your insurance, we strongly suggest that you get a first and last name of whoever you talk to there and that you save all Explanation of Benefits, letters, telephone messages etc. You may also find that when you deal with your insurance company that the insurance company simply does not know the answers to your questions. This is because many insurance companies hire many people who are not educated enough for their job and do not understand the insurance anymore than you do. Be patient and perhaps our staff can also help you in this regard.
G. Utilization Review Committee
We have noticed in this office that Health Maintenance Organizations are always checking their utilization. There is a committee called The Utilization Review Committee who checks most claims. If they decide after the service is performed (and even after the FIMO has paid your bill), that this was a bill that they claim that they should not have paid or decide that they do not want to pay it, they can demand a refund from this office. We have had cases where the bill has been entirely taken care of by the insurance company and then several months later the insurance company decides that it should not have paid that bill and demands a refund from us. We are contractually bound to issue that refund to that HMO. Unfortunately this means that instantly you will have a balance with us again, because we did provide a service for you. This is very frustrating to you and we completely understand that, but it is a function of the quality of your HMO and your health insurance dollars. You are expected to pay immediately if this situation ever occurs.
III. Medicare
Medicare participants must understand that there are not many things in dentistry that Medicare will pay for. We will therefore ask you to sign a statement to this effect and you will be required to pay fee for service for your dental services. If there is something that is covered by Medicare, we are Medicare participating providers and we will be happy to work with you on it.
IV. Medicaid/ Mainecare – We no longer participate with the Mainecare or Medicaid insurance program.
You must understand that there are some very strict rules and regulations regarding what is covered and what is not covered under Medicaid. Basically~ Medicaid pays for the extraction of teeth when:
A. An individual tooth is causing pain and infection or,
B. If the removal of teeth is implicated because of the patient’s medical condition.
It is very possible to have a situation where many teeth may need to be removed, but they do not meet these two rules. In this case, you will be informed that Medicaid will not cover this work and YOU WILL BE REQUIRED TO PAY FOR IT YOURSELF. These fees will be collected from you at the time of the service. You must also understand that Medicaid in the State of Maine is experimenting heavily with a managed care format and that the fees to providers are dramatically dropping. With this in mind, more and more doctors and dentists every day are refusing to accept Medicaid patients. This is making it harder and harder for Medicaid recipients to find care. This office frequently sees patients from a four or five hour drive away. Because of our dedication to all patients, Medicaid or otherwise, this can present scheduling difficulties and we ask for your patience while we try to solve them. Please be reassured that if you are a Medicaid recipient, you will be treated like any other patient in this office.
Again, we no longer participate with the Mainecare or Medicaid insurance program. THis information is available fir informational purposes only.
V. Care Credit
This company specializes in providing credit to patients purely for medical or dental procedures. We have the applications here in this office and if you will take the time to fill them out while you are here, we can fax in these applications for a specific dollar amount line of credit and frequently we can get an answer back within just a few hours as to whether you will be approved for it. If you are approved, you can proceed ahead and have the work done and we will automatically submit the bill to the company and they will automatically pay it. There are several other dentists and physicians in town which also accept this and it could be very convenient for you. Please be advised that approval or denial of credit from this company is purely a function of your credit history. We have no input whatsoever into it and if you are denied, it is purely your responsibility and that of the company.
VI. Miscellaneous Information
Please be advised that any estimates that we give you are good for six months from the time that they are issued. After that time, they may be subjected to any fee schedule revisions that this office chooses to implement.
VII. Divorced Parents
Despite whatever divorce agreement arrangements that have been established between two divorced parents. the parent that brings in the child will be the one who is initially responsible for the bill. The only exception to this will be if we receive a communication from the other parent and they give us permission to use their insurance and their insurance does indeed prove to be valid.
VIII. Complaints About Insurance Companies
If you have any problems with your insurance company; you should know that you do have some rights under Maine State Law. If you are angry with the insurance company, or feel that they have not been honest with you or have not provided you with what you feel you paid for in premiums, you have the right to complain to the Maine State Insurance Commissioner We have forms for this in the office and we encourage people if they have the slightest unhappiness With their insurance company to file one. We cannot promise a positive outcome, but you send a strong message to your employer and the insurance company by filing complaints. If an insurance company has a large number of complaints filed against it, it will be very thoroughly investigated by the state and it does run the risk of losing its license.
Lastly, we want you to know that we are always willing to talk to you about your account. Our business administrator and office manager are the people to ask to speak to when you call. We understand how complicated the insurance world is now and our staff is continually going to courses and training to understand the various insurances and HMOs. We know how difficult it must be for you who do not have access to these courses to even understand your own insurance, so we will be happy to work with you on it. Please be patient with us and do not view us as adversaries. We want you to get the best help that you can get.