Billing Information
Understanding the billing policies of health insurance providers and your Primary Care Provider can be a confusing process. As part of our commitment to serving our patient’s needs, we’ve created a resource guide to help you better understand the financial and billing policies at Southwest Orlando Family Medicine, P.L. We are committed to providing you with the best possible care and helping you remain eligible for your health benefits. At the end of each office visit, your patient care summary will be available on our Patient Portal, summarizing procedures, tests, and charges rendered to you at the time of service.
Fees, Payments, and Insurance
Southwest Orlando Family Medicine, P.L. participates and accepts assignment with most insurance companies and collect the amount due based on the amount allowed by your insurance. This can include co-pays, deductibles, and any pending balances. As a courtesy to you, we file your claim with your insurance carrier. However, we recommend that you always familiarize yourself with your health insurance policy and bring any required forms to your visit.
Notify us of any changes to your insurance coverage as soon as possible. Having the most current information is vital in preventing unnecessary delays in the billing process. Health insurance costs often include (but are not limited to) co-pays, deductibles, laboratory fees, diagnostic/free standing facilities, walk-in urgent care facilities, and hospitals in and out of your insurance network.
Patients are responsible for any expenses incurred for services rendered by labs, facilities, or medical providers that are out of network.
If you have any questions, please reach out to one of our office managers or call our billing department at 407-352-9717.
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
- Severity of Health Conditions
- Place of Service
- Intensity of Service (labs, x-rays, ultrasounds, and other required tests)
What Determines the Amount I Should Pay?
If you are covered under health insurance, the best place to learn about your coverage and benefits is through your health plan’s Summary of Benefits, Evidence of Coverage, and any other material provided to you by your insurance company. 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, by providing you with an 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 are in-network with Southwest Orlando Family Medicine, P.L.
Insurance Plans We Accept
We accept health plans from most insurance carriers. We also offer a payment plan for patients with and without health insurance. 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 (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.
If you carry a Health Maintenance Plan, or HMO, you must call them to change your PCP. They will establish an effective date. Our office cannot schedule you until this step is completed. Some insurance companies have deadlines, so depending on when you call, you may not become effective with our office until the following month. The practice accepts most insurance plans. Because every plan and policy is unique, we recommend that our patients familiarize themselves with their insurance coverage including: co-payment amounts, whether any coinsurance percentages or deductibles apply, whether insurance referrals to specialists are required, and radiology imaging coverage.
Insurances we accept:
PPO, EPO, POS
HMO
Aetna
Yes
We do not accept: Aetna Medicare HMO
Florida Blue (Blue Options Network, Blue Select)
Yes
No
Cigna
Yes
No
Freedom Healthcare / Optimum
Yes
Humana commercial
Yes
Yes
Medicare & Medicare Advantage plans
Yes
We accept AARP Medicare Complete, Humana Gold Plus HMO, WellMed
United Healthcare
Yes (No Bronze or Silver)
Yes
WellCare
Yes
Please reach out to your insurance provider for a list of your in-network health care providers.
Financial Policy
- Payment is due at the time service is rendered. Patients with insurance coverage are required to pay their deductible, co-insurance, or co-pay at the time service is rendered. Patients without insurance coverage are responsible for cost of services. We offer Payment Plans for all patients, please inquire at our office.
- Your health insurance plan is a contract between you and your insurance provider, and benefits may vary depending on your plan.
- By selecting Southwest Orlando Family Medicine, P.L. as your Primary Care Provider (PCP), you are responsible for any balance due after your primary insurance has processed your claim. Any co-pays, 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, so we can work together to resolve any issues. Not all insurance plans cover all services. In the event your insurance plan determines a service is not covered, you will be responsible for the complete charge.
- We accept cash, check, and most major credit cards. Returned checks will assess a fee of $30. We are unable to honor postdated checks.
- Patients are required to provide a minimum 24-hour notice to cancel or reschedule their appointment, otherwise a $25 no-show or same-day cancellation fee will be charged.
- If you miss a diagnostic procedure (Ultrasound, Nerve Conduction Study, Urodynamics Testing, etc.), a $75 no-show fee will be charged.
- All payments are due upon receipt of a statement from our office. Balances over 60 days old from the statement date will be sent to an outside collection agency. Patients who fail to pay or arrange a payment plan may be discharged from Southwest Orlando Family Medicine, P.L.
- It is your responsibility to be an active participant in your health care by knowing your insurance benefits.
- Southwest Orlando Family Medicine, P.L. is unable to retroactively change your claim’s diagnosis codes post visit, regardless of what your insurance carrier might suggest. This includes changing the code or visit type for laboratory orders requested at a consult visit. This is considered insurance fraud and is illegal.
We understand that temporary financial problems may affect timely payment of your account balance. Please reach out to our billing department for assistance in the management of your account.
What to Know About Health Insurance
Health insurance covers the costs of medical care and offers many important benefits:
- Covers essential health benefits
- Protects from unexpected, high medical costs
- Provides low cost or no cost preventive care
- Offers lower costs for covered, in-network health care
- Exemption from the ACA tax penalty for going without coverage
This guide will help you navigate through all the health insurance plans available so that you can select the one that best meets your financial and health care needs.
How do insurances work
Health insurance plans require a monthly payment (premium) in order to keep insurance coverage. This monthly payment may be paid by you or by your employer. You may also pay to receive medical care, in the form of a co-pay, deductible, or co-insurance. Coverage for medical services vary from plan to plan. Generally, the higher the premium, the lower the co-pay, deductible, and out-of-pocket cost.
Once the out-of-pocket maximum is met, your health insurance plan will pay all covered services for the remainder of the plan 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.
Some health plans may have co-pay and co-insurance for specific services. Make sure to read your 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?
No plan is necessarily better than another. 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/
Southwest Orlando Family Medicine, P.L. participates and accepts assignment with most insurance companies and collect the amount due based on the amount allowed by your insurance. This can include co-pays, deductibles, and any pending balances. As a courtesy to you, we file your claim with your insurance carrier. However, we recommend that you always familiarize yourself with your health insurance policy and bring any required forms to your visit.
Notify us of any changes to your insurance coverage as soon as possible. Having the most current information is vital in preventing unnecessary delays in the billing process. Health insurance costs often include (but are not limited to) co-pays, deductibles, laboratory fees, diagnostic/free standing facilities, walk-in urgent care facilities, and hospitals in and out of your insurance network.
Patients are responsible for any expenses incurred for services rendered by labs, facilities, or medical providers that are out of network.
If you have any questions, please reach out to one of our office managers or call our billing department at 407-352-9717.
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
- Severity of Health Conditions
- Place of Service
- Intensity of Service (labs, x-rays, ultrasounds, and other required tests)
What Determines the Amount I Should Pay?
If you are covered under health insurance, the best place to learn about your coverage and benefits is through your health plan’s Summary of Benefits, Evidence of Coverage, and any other material provided to you by your insurance company. 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, by providing you with an 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 are in-network with Southwest Orlando Family Medicine, P.L.
Insurance Plans We Accept
We accept health plans from most insurance carriers. We also offer a payment plan for patients with and without health insurance. 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 (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.
If you carry a Health Maintenance Plan, or HMO, you must call them to change your PCP. They will establish an effective date. Our office cannot schedule you until this step is completed. Some insurance companies have deadlines, so depending on when you call, you may not become effective with our office until the following month. The practice accepts most insurance plans. Because every plan and policy is unique, we recommend that our patients familiarize themselves with their insurance coverage including: co-payment amounts, whether any coinsurance percentages or deductibles apply, whether insurance referrals to specialists are required, and radiology imaging coverage.
Insurances we accept:
PPO, EPO, POS
HMO
Aetna
Yes
We do not accept: Aetna Medicare HMO
Florida Blue (Blue Options Network, Blue Select)
Yes
No
Cigna
Yes
No
Freedom Healthcare / Optimum
Yes
Humana commercial
Yes
Yes
Medicare & Medicare Advantage plans
Yes
We accept AARP Medicare Complete, Humana Gold Plus HMO, WellMed
United Healthcare
Yes (No Bronze or Silver)
Yes
WellCare
Yes
Please reach out to your insurance provider for a list of your in-network health care providers.
Financial Policy
- Payment is due at the time service is rendered. Patients with insurance coverage are required to pay their deductible, co-insurance, or co-pay at the time service is rendered. Patients without insurance coverage are responsible for cost of services. We offer Payment Plans for all patients, please inquire at our office.
- Your health insurance plan is a contract between you and your insurance provider, and benefits may vary depending on your plan.
- By selecting Southwest Orlando Family Medicine, P.L. as your Primary Care Provider (PCP), you are responsible for any balance due after your primary insurance has processed your claim. Any co-pays, 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, so we can work together to resolve any issues. Not all insurance plans cover all services. In the event your insurance plan determines a service is not covered, you will be responsible for the complete charge.
- We accept cash, check, and most major credit cards. Returned checks will assess a fee of $30. We are unable to honor postdated checks.
- Patients are required to provide a minimum 24-hour notice to cancel or reschedule their appointment, otherwise a $25 no-show or same-day cancellation fee will be charged.
- If you miss a diagnostic procedure (Ultrasound, Nerve Conduction Study, Urodynamics Testing, etc.), a $75 no-show fee will be charged.
- All payments are due upon receipt of a statement from our office. Balances over 60 days old from the statement date will be sent to an outside collection agency. Patients who fail to pay or arrange a payment plan may be discharged from Southwest Orlando Family Medicine, P.L.
- It is your responsibility to be an active participant in your health care by knowing your insurance benefits.
- Southwest Orlando Family Medicine, P.L. is unable to retroactively change your claim’s diagnosis codes post visit, regardless of what your insurance carrier might suggest. This includes changing the code or visit type for laboratory orders requested at a consult visit. This is considered insurance fraud and is illegal.
We understand that temporary financial problems may affect timely payment of your account balance. Please reach out to our billing department for assistance in the management of your account.
What to Know About Health Insurance
Health insurance covers the costs of medical care and offers many important benefits:
- Covers essential health benefits
- Protects from unexpected, high medical costs
- Provides low cost or no cost preventive care
- Offers lower costs for covered, in-network health care
- Exemption from the ACA tax penalty for going without coverage
This guide will help you navigate through all the health insurance plans available so that you can select the one that best meets your financial and health care needs.
How do insurances work
Health insurance plans require a monthly payment (premium) in order to keep insurance coverage. This monthly payment may be paid by you or by your employer. You may also pay to receive medical care, in the form of a co-pay, deductible, or co-insurance. Coverage for medical services vary from plan to plan. Generally, the higher the premium, the lower the co-pay, deductible, and out-of-pocket cost.
Once the out-of-pocket maximum is met, your health insurance plan will pay all covered services for the remainder of the plan 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.
Some health plans may have co-pay and co-insurance for specific services. Make sure to read your 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?
No plan is necessarily better than another. 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/
We accept health plans from most insurance carriers. We also offer a payment plan for patients with and without health insurance. 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 (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.
If you carry a Health Maintenance Plan, or HMO, you must call them to change your PCP. They will establish an effective date. Our office cannot schedule you until this step is completed. Some insurance companies have deadlines, so depending on when you call, you may not become effective with our office until the following month. The practice accepts most insurance plans. Because every plan and policy is unique, we recommend that our patients familiarize themselves with their insurance coverage including: co-payment amounts, whether any coinsurance percentages or deductibles apply, whether insurance referrals to specialists are required, and radiology imaging coverage.
Insurances we accept:
| PPO, EPO, POS | HMO | |
| Aetna | Yes | We do not accept: Aetna Medicare HMO |
| Florida Blue (Blue Options Network, Blue Select) | Yes | No |
| Cigna | Yes | No |
| Freedom Healthcare / Optimum | Yes | |
| Humana commercial | Yes | Yes |
| Medicare & Medicare Advantage plans | Yes | We accept AARP Medicare Complete, Humana Gold Plus HMO, WellMed |
| United Healthcare | Yes (No Bronze or Silver) | Yes |
| WellCare | Yes |
Please reach out to your insurance provider for a list of your in-network health care providers.
Financial Policy
- Payment is due at the time service is rendered. Patients with insurance coverage are required to pay their deductible, co-insurance, or co-pay at the time service is rendered. Patients without insurance coverage are responsible for cost of services. We offer Payment Plans for all patients, please inquire at our office.
- Your health insurance plan is a contract between you and your insurance provider, and benefits may vary depending on your plan.
- By selecting Southwest Orlando Family Medicine, P.L. as your Primary Care Provider (PCP), you are responsible for any balance due after your primary insurance has processed your claim. Any co-pays, 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, so we can work together to resolve any issues. Not all insurance plans cover all services. In the event your insurance plan determines a service is not covered, you will be responsible for the complete charge.
- We accept cash, check, and most major credit cards. Returned checks will assess a fee of $30. We are unable to honor postdated checks.
- Patients are required to provide a minimum 24-hour notice to cancel or reschedule their appointment, otherwise a $25 no-show or same-day cancellation fee will be charged.
- If you miss a diagnostic procedure (Ultrasound, Nerve Conduction Study, Urodynamics Testing, etc.), a $75 no-show fee will be charged.
- All payments are due upon receipt of a statement from our office. Balances over 60 days old from the statement date will be sent to an outside collection agency. Patients who fail to pay or arrange a payment plan may be discharged from Southwest Orlando Family Medicine, P.L.
- It is your responsibility to be an active participant in your health care by knowing your insurance benefits.
- Southwest Orlando Family Medicine, P.L. is unable to retroactively change your claim’s diagnosis codes post visit, regardless of what your insurance carrier might suggest. This includes changing the code or visit type for laboratory orders requested at a consult visit. This is considered insurance fraud and is illegal.
We understand that temporary financial problems may affect timely payment of your account balance. Please reach out to our billing department for assistance in the management of your account.
What to Know About Health Insurance
Health insurance covers the costs of medical care and offers many important benefits:
- Covers essential health benefits
- Protects from unexpected, high medical costs
- Provides low cost or no cost preventive care
- Offers lower costs for covered, in-network health care
- Exemption from the ACA tax penalty for going without coverage
This guide will help you navigate through all the health insurance plans available so that you can select the one that best meets your financial and health care needs.
How do insurances work
Health insurance plans require a monthly payment (premium) in order to keep insurance coverage. This monthly payment may be paid by you or by your employer. You may also pay to receive medical care, in the form of a co-pay, deductible, or co-insurance. Coverage for medical services vary from plan to plan. Generally, the higher the premium, the lower the co-pay, deductible, and out-of-pocket cost.
Once the out-of-pocket maximum is met, your health insurance plan will pay all covered services for the remainder of the plan 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.
Some health plans may have co-pay and co-insurance for specific services. Make sure to read your 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?
No plan is necessarily better than another. 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/
Health insurance covers the costs of medical care and offers many important benefits:
- Covers essential health benefits
- Protects from unexpected, high medical costs
- Provides low cost or no cost preventive care
- Offers lower costs for covered, in-network health care
- Exemption from the ACA tax penalty for going without coverage
This guide will help you navigate through all the health insurance plans available so that you can select the one that best meets your financial and health care needs.
How do insurances work
Health insurance plans require a monthly payment (premium) in order to keep insurance coverage. This monthly payment may be paid by you or by your employer. You may also pay to receive medical care, in the form of a co-pay, deductible, or co-insurance. Coverage for medical services vary from plan to plan. Generally, the higher the premium, the lower the co-pay, deductible, and out-of-pocket cost.
Once the out-of-pocket maximum is met, your health insurance plan will pay all covered services for the remainder of the plan 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.
Some health plans may have co-pay and co-insurance for specific services. Make sure to read your 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?
No plan is necessarily better than another. 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/
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/