Understanding Insurance Coverage
Fees & Payments
Anticipated Co-Insurance Payment Policy
Self-Pay Financial Status Policy
Out of Sate and Out of Country Financial Status Policy
Legal Representation & Litigation Policy
Durable Medical Goods Policy
Miscellaneous Form Fee Policy
Surgical Procedure Billing Pollicies

Typically all insurance plans are structured to have an individual policyholder deductible, terms of reimbursement after deductible has been satisfied (i.e. 70/30, 80/20, etc) and a plan maximum out of pocket clause.

The individual policyholder deductible is the amount that the policyholder must pay out-of-pocket before the insurance starts paying insurance claims. For example, if your plan deductible is $1,000, your insurance company will receive medical claims and process them through their system; the insurance carrier will not issue payment until they have processed $1,000 worth of billable charges and in their system deemed $1000 worth of billable charges as “patient responsibility”. Once the insurance company has processed $1,000 worth of charges into their system, they will begin to issue payment to medical providers according to the terms and conditions of the contract.

Terms of reimbursement after deductible identifies the plan structure outlining what percentage the patient is responsible for and what percentage the insurance company will pay. For example, if the plan coverage is outlined as 70/30, the insurance company will pay 70% and the patient is responsible for the other 30%.

Example:

Plan	Billed Amount	Insurance Payment	Patient Responsibility
80/20	$100.00	$80.00	$20.00
70/30	$100.00	$70.00	$30.00
50/50	$100.00	$50.00	$50.00

If the insurance carrier does not have a contract with Peak Orthopaedics, PLLC and deems a portion of the charges not “reasonable & customary”, the patient is still responsible for that portion of the bill.

Example 1: Insurance Processing Claim: 70/30 Plan, No Contract with Provider

Billed Amt	Allowed Amt	Adj Portion	Insurance Payment	Patient Responsibility
$100.00	$100.00	$0.00	$70.00	$30.00
$200.00	$180.00	$20.00	$126.00	$74.00
$300.00	$250.00	$50.00	$175.00	$125.00

Note: In this scenario, if your insurance company does not have a contract with the provider, the insurance will pay 70% of the billable amount they arbitrarily determine reasonable and customary. As the subscriber you are responsible for the 30% of the billable portion they arbitrarily determine reasonable and customary as well as the portion they have “adjusted” from processing.

Example 2: Insurance Processing Claim: 70/30 Plan with Preferred Provider Contract

Billed Amt	Allowed Amt	Adj Portion	Insurance Payment	Patient Responsibility
$100.00	$100.00	$0.00	$70.00	$30.00
$200.00	$180.00	$20.00	$126.00	$54.00
$300.00	$250.00	$50.00	$175.00	$75.00

Note: In this scenario, since your insurance carrier has a contractual agreement with the provider, the “allowed amount” has been negotiated under the terms and conditions of that contract; therefore the subscriber is not responsible for that adjusted amount.

Once your insurance carrier pays their portion of the bill, they will send you and explanation of benefits (EOB) to show how the claim was processed and paid. You can compare your EOB to the bill sent by Peak Orthopaedics, PLLC. How the carrier paid the claim is based on their contract with us and their contract with you. If you feel the insurance company should have paid a higher amount, please contact them directly for resolution.

Many insurance plans have a maximum out-of-pocket clause. This means that once you have met the maximum out-of-pocket clause amount (i.e. $10,000) they will increase their reimbursement to 100%. For example, if your original contract is a 70/30 plan, the insurance will pay 70% of charges until the participant has paid $10,000 in co-payments and co-insurance; at which time the insurance will increase their reimbursement from 70% to 100% where after the patient will no longer have any out-of-pocket expenses. The maximum out-of-pocket clause typically only applies to that calendar year’s coverage; the out-of-pocket max will begin re-accumulating the next calendar year.

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Fee Schedule
We review our fee schedule on a yearly basis to assure our fees are fair and reasonable. The formula we use to determine our fee scheduled is based upon data collected in accordance with Medicare’s relative value scale as well as a fee analysis and relative value unit study for our geographical area to assure that we are within the midline percentage of that study.

If we do not have a contractual agreement with your insurance carrier, we do not accept the “usual and customary” fee schedule that they have developed. You will be responsible for the entire billed amount.

If we do have a contract with your insurance carrier, we have accepted their fee schedule and you will only be responsible for the “allowable” amount per the terms and conditions of the contract.

Payment Methods
We accept cash, checks, Visa and MasterCard.

Financial Hardships
We have financial hardship programs available to assist patients without insurance or patients with high co-insurance balances. You can meet with our Billing Department or Practice Manager to discuss these options. If we have a contractual agreement with your insurance carrier you are exempt from these programs as a discount has already been honored under the terms and conditions of the contract.

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Our facility has implemented a $25.00 “anticipated co-insurance payment” that patients are required to pay at check-in of every office visit.

If your insurance card indicates that you have a visit co-payment higher than our policy, you will be required to make that greater payment to be compliant with the terms and conditions of the contract you have with your insurance carrier.

Anticipated “co-insurance” represents the portion of the bill that will be deemed “patient responsibility” after the insurance carrier has processed the charges. Typically, this portion is determined based upon the structure of the patient’s insurance coverage (i.e. deductible, terms of reimbursement, non-covered services, etc.)

Because we want a patient’s insurance company to process 100% of the billed charges and not deduct the payment we required the patient make on the “front end”, anticipated co-insurance payments made at the time of service will be posted to the patient’s account in “unapplied credit”. The payment will be posted with a reference memo indicating the payment was received from the patient and the date of service the funds are reserved for. It is against our billing department guidelines to “cross-allocate” unapplied credit amounts amongst different dates of service without communicating such with the patient; this ensures a cleaner audit trail.

Please note, our practice management software does not clearly identify the “unapplied credit” amounts that are pending allocation on an account; these amounts will not appear on your patient statement under “patient payments” until they have been taken out of unapplied credit and allocated to that specific line item. If at any time you wish to verify that a co-insurance payment credit is on your account and pending allocation, please feel free to contact our Billing Department.

Once the insurance carrier has processed all claims for a given date of service, if any overpayments occur, patients will be refunded at that time. Overpayment refunds are processed out of our Bookkeeping Department twice per month.

The only exceptions to co-insurance payments are as follows:

Patients with Medicare as their primary insurance with a supplemental.
2. Patients with Medicaid fall under Medicaid guidelines.
3. BCBS Chip Participants fall under those plan guidelines.
4. Third Party Liability Verification (100% in Writing).
5. Worker’s Compensation/Industrial Injury patients with a claim number.

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Patients without insurance are requested to pay in full at the time of service. Special arrangements need to be authorized by the practice manager prior to the scheduled appointment. We accept cash, check, Visa and MasterCard as payment methods.

Our Billing Department is available to discuss financial hardships and payment contract opportunities.

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Patients from out-of-state and out-of-country must pay in full at the time of service. We do accept cash, check, Visa and MasterCard as a payment method.

As a courtesy, we will submit your claim(s) to your insurance company if you have been compliant with our admission policy and provided us with applicable insurance information and/or a copy of your insurance card.

Upon receipt of your insurance carrier processing the claim, you will be reimbursed any payment they issue in full.

Please note that we do not have any contractual agreements with out-of-state or out-of-country insurance carriers.

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If you are being represented by legal counsel or if your claim is in litigation, you will be registered as a self-pay status requiring you to be compliant under those financial obligations.

Peak Orthopaedics, PLLC will not bill at attorney’s office. It will be the patient’s responsibility to forward billing statements to their attorney. Our Billing Department is available to discuss any financial hardships and develop a payment arrangement agreement pending legal litigation settlement.

Once a legal case is settled, if there is any patient overpayment identified, the patient will be refunded accordingly.

We encourage patients to sign a release of information authorization at their attorney’s office which will give their attorney access to their medical records at our facility which will assist in the litigation process.

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Patients requiring durable medical goods (i.e. braces, casting supplies, injection medications, etc.) will be required to pay for these products in full at the time of service/distribution. These products will only be distributed if the treating physician deems them medically necessary.

Patients of Peak Orthopaedics, PLLC will be required to sign an Advanced Beneficiary Notice (ABN) at the time these products are distributed identifying the item description, fee for the item and a patient signature accepting financial liability.

Our facility requires patient’s to accept financial liability for these products because many insurance carriers do not cover these products or often times their reimbursement fee schedule is far below our direct “cost” for the product(s). Peak Orthopaedics, PLLC has not set the fee schedule for durable medical goods at a retail rate; we continually audit our supply invoices to assure the fee schedule for these products is fair.

Patients can inquire to see if the product being deemed medically necessary by their physician is available from an outside vendor (i.e. pharmacy or medical supply company); if the product is available from an outside vendor, the physician can issue a written prescription for this product if the patient chooses to use that resource instead of our facility. Many outside vendors have a durable medical good license and will bill a patient’s insurance carrier for these products with a physician’s prescription. The only disadvantage this can sometimes pose to the subscriber of the insurance policy is that their co-insurance balance is quite high due to the retail fee schedule of these products.

As a courtesy, Peak Orthopaedics, PLLC will bill your insurance for these durable medical goods with a modifier noting that a signed Advanced Beneficiary Notice is on file. If your insurance company processes the charge and issues any payment, you will be reimbursed accordingly. Peak Orthopaedics, PLLC will not accept any contractual fee schedule discounts for durable medical goods.

Durable medical goods are non-returnable and non-refundable.

Peak Orthopaedics, PLLC does support a Shepherd’s Hand Program if patients wish to donate used durable medical goods back to the facility to be recycled and distributed to someone in need with an extreme financial hardship situation.

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All patients will be required to pay an $8.00 form fee (per page) for miscellaneous paperwork requested for completion; this includes disability paperwork, deferred loan payment paperwork, etc.

Please allow a one week turnaround time for this paperwork to be completed. Peak Orthopaedics, PLLC will contact the patient once the form is completed and signed by their physician.

A copy of the completed form will become part of the permanent medical record at Peak Orthopaedics, PLLC.

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Thank you for choosing Peak Orthopaedics, PLLC for your medical needs. We look forward to assisting you through your recovery process with a goal of getting you back to an active lifestyle. This letter was developed to help educate you on the surgical billing protocol. Typically you will receive at least three bills from your surgery; one from your physician’s office, one from the hospital where the procedure was performed and another from the anesthesiologist’s billing office. If your case requires an assistant surgeon, you will also receive a bill for those services.

Your physician will be coding the surgical procedure performed. We use CPT codes to identify the procedure that was performed; often times there are multiple procedure codes that are billed out to describe the procedure performed by the physician. All procedures will be billed to your insurance company at 100% the billable rate. Billing guidelines identify if a procedure is considered a separate procedure, which means those procedures are billable and payable at 100% of the billable rate; other procedures are considered “multiple procedures in the same operative session” which means the “primary” procedure is billable and payable at 100% and the “multiple procedures” are processed at 50% the billable rate.

If your procedure required an assistant surgeon, the assistant surgeon bills the identical procedures and rates that the physician billed; but according to billing guidelines those charges are appended with a “modifier” which identifies services were performed by an assistant surgeon and typically these charges are processed at 20% of the physician’s billable amount if the assistant is another physician or physician’s assistant and 10% of the physician’s billable amount if the assistant is considered a “minimal assist” such as a CRNFA (certified registered nurse first assist). Charges for the assistant surgeon also fall under the coding guidelines identified above in regards to separate and multiple procedures performed in the same operative session.

Accounts are reviewed after your insurance company processes the claim to assure that all applicable discounts have been applied.

The procedure performed by your physician typically has a 90 day global period, which means that your follow-up office visits for 90 days past surgery are included in the surgical fee. The only additional costs you will have in this global period would be x-rays, durable medical goods (braces) or casting application and casting supply fees. You would also have office visit charges in this global period if you saw the physician for a different injury or anatomical site in the global period.

Please contact our Billing Department at 406-863-9340 if you need to sign a payment contract and/or inquire about financial options regarding your remainder balance.

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