Billing Information

It is the patient’s responsibility to understand the different policies and contracts that they enter when enrolling in a health insurance plan. We try to make this process easier for patients by providing them with resources to better understand the different financial and billing policies. Click on sub-headings below to read more.

Cost of Medical Care

What is it Going to Cost Me?
Understanding your cost of the medical care you receive can be confusing and stressful, but is an important part of managing your healthcare. The provided guide shows you typical costs for our office for common medical services and treatments.

Factors That Determine the Cost?

  • The severity of your health conditions
  • Place of Service
  • Intensity of service such as: number of labs, x-ray’s, ultrasounds, and other required tests

What Determines the Amount I Should Pay?

If you are covered under healthcare insurance, the best place to learn about your coverage and benefits is through your health plan’s Summary of Benefits, Evidence of Coverage, and other plan information material that was mailed to you by your insurance company. You can also check your updated insurance card for cost information of co-pays. Your insurance card will also have a Customer Service number for you to call and speak to a live representative regarding coverage and benefits.

Our office is here to help too. Our office can provide you with a Care Estimate of how much your visit will be based on contracted amounts with your insurance and real time eligibility checks.

Pricing for common care services are listed below. Some services may not be listed.

Care received from Office visit Cost Estimate

Complete Physical Exam

*Most major health insurances cover Complete Physical Exams under preventative benefits. For more information on what a Complete Physical Exam includes, click here.

Child Exam (5–11yrs old) $80 – $280
Child Exam (12–17yrs old) $90 – $220
Adult Exam (18–39yrs old) $90 – $270
Adult Exam (40–64yrs old) $100 – $280
Adult Exam (65yrs & older) $110 – $300

Follow-ups and Sick Visits

(includes office visit and common tests)

Common sick visits include but are not limited to: muscle pain, common cold, flu, UTI, URI, headaches/migraines $20 – $230

Immunizations (varies on specific vaccine and quantity)

$20 – $230

Diagnostic Tests and Lab Services

Allergy Studies $200 – $480
Electrocardiogram (EKG) $16 – $45
Pulmonary Studies $30 – $125
Blood Count (varies on specific tests and quantity) $15 – $400
Urinalysis/Pregnancy Test $3 – $27
In-House Lab testing (Microalbumin, Hemoglobin, Quick Strep, Rapid Flu) $3 – $150

**Please note that coverage of benefits varies from plan to plan. The rates above are based on contracted rates from insurance plans that we are in-network with.

Insurance Plans We Accept

We accept health plans from most insurance carriers. For those without health insurance, a payment plan can be set up. If you do not see your insurance listed, please contact the office.

Please be advised that our office, Southwest Orlando Family Medicine, P.L., does NOT accept any form of Medicaid insurance (i.e. HealthEase Kids, Staywell, Florida Medicaid, Sunshine State Health Plan, UnitedHealth Community Plan, etc.). Patients with Medicaid or any other out-of-network insurance will need to call their insurance to locate an in-network provider.

Insurances we accept:

PPO, EPO, POS HMO
Aetna
Yes
Yes
Florida Blue (Blue Care, Blue Options Network Blue, Blue Select, Federal, myBlue, myTime)
Yes
Yes
Cigna
Yes
Yes
FMH
Yes
Florida Hospital (HealthFirst)
Yes
Humana commercial
Yes
Yes
Medicare & Medicare Advantage plans
Yes
We only accept AARP Medicare Complete, Blue Medicare HMO*, Humana Gold Plus GMO, Wellmed, Simply HMO
*We are NOT in network with Blue Medicare HMO Plus. We are NOT in network with Medicaid.
United Healthcare
Yes
We do not accept Compass, Navigate, Core plans, Neighborhood.
Tricare
Yes

Select, Standard, and For Life (Out-of-network benefits will be used)

We do not accept Tricare Prime.

Financial Policy

We are committed to providing you with the best possible care. If you have medical insurance, we would like to help you receive your maximum allowable benefits.

  • Payment is due at the time service is rendered. For those patients with insurance coverage, it will be necessary for you to pay your deductible, co-insurance, or co-payment at the time service is rendered.
  • You should be aware that your insurance is a contract between you and the insurance company. We file insurance claims as a courtesy to you. However, you will be responsible for all unpaid balances. Insurance plans differ, depending on the contract your employer has negotiated. It is your responsibility as a patient to become an active participant in your own health care and know your insurance benefits.
  • For any insurances plans that we do not participate with and are considered out-of-network providers, including all forms of Medicaid, services rendered will not be billed. By selecting our practice as your Primary Care Physicians, you assume financial responsibility for any balance due after your primary insurance has processed your claim. Any co-payments, deductibles, and non-covered service charges left by the primary insurance will be the patient’s responsibility.
  • By law, your insurance carrier must remit payment or deny your insurance claim within 30 days of initial notice of claim. If an insurance problem occurs, you will be asked to assist us in contacting your insurance carrier, as we feel it is necessary to work together to resolve any insurance problem. Not all insurance plans cover all services. In the event your insurance plan determines a service to be “not covered” you will be responsible for the complete charge.By law, your insurance carrier must remit payment or deny your insurance claim within 30 days of initial notice of claim. If an insurance problem occurs, you will be asked to assist us in contacting your insurance carrier, as we feel it is necessary to work together to resolve any insurance problem.
  • We accept cash, check, MasterCard, Visa, Discover & American Express. Our fee for a returned check is $25.00-$30.00. We are unable to honor postdated checks.
  • If you are unable to keep your appointment, kindly give our office a minimum 24 hours’ notice, otherwise a $25 no-show or same-day cancellation fee will be charged. Regretfully, we had to implement this policy in order to give other patients the opportunity to be cared for in a timely manner. This will also ensure that our provider’s times are efficiently utilized.
  • If you miss a diagnostic procedure (e.g. Dexa Scan, Ultrasound, Nerve Conduction Study, VNG Testing, Urodynamics Testing, etc.), a $75 no-show fee will be charged.
  • We request that you call at least 24-hours prior to your appointed time either to cancel and/or reschedule your appointment.
  • All payments are due upon receipt of a statement from our office. Balances over sixty days (60) old from the date of service will be sent to an outside collection agency and may result to discharge of the practice, unless prior arrangements have been made with our billing office.

We understand that temporary financial problems may affect timely payment of your account. If such problems arise, we encourage you to contact us for assistance in the management of your account.

What you need to know about health insurances

Choosing a health insurance can be confusing, and it is important that you understand health insurance basics in order to choose the right one for that meets your budget and healthcare needs.

Health insurance covers the costs of medical care and offers many important benefits:

  • Covers essential health benefits
  • Protects you from unexpected, high medical costs
  • Allows you to pay less for covered in-network health care
  • Preventive care
  • Exemption from the penalty that people without coverage must pay

This guide will help you navigate through all the health insurance plans available so that you can select the one that is right for you.

How do insurances work

No matter what insurance you choose, there will always be a monthly payment (premium) in order for you to keep health insurance coverage. You may also have to pay each time you receive medical care (either a co-payment, deductible, or co-insurance). Generally, the higher the premium, the lower your co-payments, deductibles and out-of-pocket costs – and vice versa.

 

 

Coverage for medical services vary from plan to plan. The term cost-sharing is used to describe the share of costs covered by your insurance that you pay out. This includes deductibles, co-insurances, and co-payments, or similar charges. This does not include premiums, balance billing amounts for out-of-network providers, or the cost of non-covered services.

When the amount you pay reaches the out-of-pocket maximum, the insurance company pays for all covered services for the remainder of the plan covered year.

Source:
https://www.healthcare.gov/why-coverage-is-important/coverage-protects-you/

Co-payments versus Deductible/Co-insurance

Healthcare services are either subject to a co-payment or a deductible. Both co-payment and deductible are forms of cost-sharing, meaning you pay part of the cost and your insurance company pays part of the cost.

Co-payments are fixed amounts that the member pays to receive healthcare services. Deductibles are contracted amounts that the health insurance requires the member to pay before your insurance starts paying for any healthcare services. Co-insurances are the percentage of the cost of the healthcare service that the member pays. Once the deductible is met, your co-insurance will apply until the out-of-pocket maximum is met for the plan year.

The advantage of the co-payment is that you know how much is due at the time of service. The co-payment will be the same for that particular service every single time. On the other hand, if the actual healthcare service costs less than the copay, you will still be expected to pay the full copay amount. Co-payments can quickly add up if you see the doctor frequently or fill lots of prescriptions.

Co-insurances do not offer the same type of predictability that the co-payment has since you won’t know how much you will owe until the service is performed. Deductible plans give you the ability to manage your own care costs to help healthy adults avoid overpaying in traditional insurance plans. You can also save on premiums with the high-deductible health plans. However, high-deductible plans are on the rise which include high co-payments, caps on hospitalization costs, and other out-of-pocket costs.

You don’t usually have to pay both a co-payment and co-insurance for the same healthcare service. However, it’s not illegal for health insurers to require this. Some health plans may have co-pays that apply in some services but are waived in others. Make sure to read the insurance plan’s benefit summary carefully when choosing a health plan.

Sources:
https://www.verywell.com/whats-the-difference-between-copay-and-coinsurance-1738506
http://www.bankrate.com/finance/insurance/a-health-plan-to-save-you-money-1.aspx

HMO, PPO, EPO, POS: Which plan is better?

There is no better insurance plan per se. There are different types of insurance plans to meet different needs for each individual. Some plans have more restrictions than others to encourage you to receive care from a preferred network of doctors, hospitals, pharmacies, and other medical service providers. Understanding the different insurance plans available will help you decide which one will best fit you and your family’s needs.

Plan Type Whom can you see? Summary
Health Maintenance Organization (HMO) Limited network, no out-of-network benefits. Generally, services must be referred by a primary care physician. Member gives up flexibility in provider choice to accept greater management of their care.
Preferred Provider Organization (PPO) Any health care provider, but benefits are reduced for out-of-network services. Member has the most flexibility with both in and out-of-network providers.
Exclusive Provider Organization (EPO) & Point of Service (POS) Generally, does not cover care outside of the plan’s network. Referral requirement varies from plan to plan. Hybrid of HMO and PPO policies. Coverage differs depending on the insurance company.

Source:
https://www.healthcare.gov/choose-a-plan/plan-types/

Basic Insurance Terminology

Co-payment
A fixed amount you pay for a covered health care service. Some plans will have a deductible that you need to meet before your co-payment can be applied.

For example, if you have a co-pay of $20 for a primary care office visit, then you will pay $20 for that office visit regardless of the amount that is charged.

Deductible

The amount you pay for covered health care services before your health insurance starts to pay. After you pay your deductible, you usually pay only a co-insurance or co-payment for covered services, and your insurance company will pay the rest.

For example, you have a $2,500 deductible. You will pay the first $2,500 of covered health services yourself before your insurance company pays.

Note that not all health services will apply towards the deductible. Some plans have separate deductibles for certain services, like prescription drugs. Some plans will also have a separate deductible for the individual to meet on their own, and a family deductible which applies to all family members.

Co-insurance
The percentage of costs of a covered health care service you pay after you’ve paid your deductible.

For example, the allowed amount for an office visit is $100 and your co-insurance is 20%. If you’ve met your deductible, you pay 20% of the $100, or $20. Your health insurance will cover the remaining 80%, or $80. If you have not met your deductible, you will pay the full allowed amount of $100.

Out-of-pocket maximum/limit
The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, co-payments, and co-insurances, your health plan pays 100% of the costs of covered services for the remainder of the plan year.

For example, you have a $5,000 out-of-pocket limit. Once you meet the $5,000 out-of-pocket limit, your health insurance will pay 100% for covered health services for the remainder of the plan year.

Allowed Amount
The maximum amount a plan will pay for a covered health care service. May also be called “contracted rate,” “eligible expense,” “payment allowance,” or “negotiated rate.”

For example, a primary care provider bills an office visit for $142. The contracted rate between the healthcare insurance and your primary care provider is an allowed amount of $100.

Premium
The amount you pay for your health insurance to remain active. Generally, an insurance with a higher premium amount will typically have lower co-payment, deductible, and out-of-pocket amounts. An insurance with a lower premium amount will have higher co-payment, deductible, and out-of-pocket amounts.

Health Reimbursement Arrangement (HRA), Health Savings Account (HSA), & Flexible Spending Account (FSA)
These are funds used to pay for qualified medical expenses, such as co-payments, deductible, and co-insurances. A debit card is usually provided to the member. An HRA allows employers to pass along savings to employees while still controlling costs. HSA’s are portable, able to earn interest and are eligible for rollover contributions. An FSA requires employees to put in money before taxes.

In-network/Preferred Provider
Facilities, providers, and suppliers your health insurance company is contracted with to provide healthcare services. Some insurance plans have a “tiered” network where you may have to pay more or less depending on their healthcare provider’s tier level.

Out-of-network/Non-preferred Provider
Facilities, providers, and suppliers your health insurance company is not contracted with to provide healthcare services. Out-of-network services usually costs more than your in-network covered benefits.

For example, an office visit to an in-network provider has a $20 co-payment, while an office visit to an out-of-network provider has a $40 co-payment. Note that some insurance plans do not have out-of-network benefits.

Sources:
https://www.uhc.com/individual-and-family/health-insurance-basics
https://www.healthcare.gov/glossary/

ePayments

Automatic Payment Plans
Our office offers customized automatic payment plans. You can now make a down payment on your balance, customize the start date, payment frequency, and installment amount. If you are unable to make your payment, kindly notify our office 2 business days prior your payment is scheduled to be taken out. The payment can be skipped and will continue when the next payment is due.

Care Estimator
Our office can provide an estimate of how much your patient responsibility will be per your insurance’s contract with real time eligibility.