Joint Replacement, Sports Medicine, Spine Surgery, Pediatric Orthopaedics, Neurology, Hand and Foot Surgery

Understanding Your Insurance

As a patient, you are responsible for knowing the provisions of your health insurance plan(s), including which physicians are in your network as well as which services need pre-certification and/or authorization prior to service(s) (labs, ultrasounds, etc.). We strongly recommend that you review your description of coverage and contact your insurance company for any questions that you may have regarding which services are covered and which are excluded or limited. It is important to understand your insurance plan’s current benefit and coverage rules, as policies and coverage determinations may vary from year to year. Failure to do so may result in a reduction of benefits or a claim denial.

Per your agreement with your insurance company, you are responsible for your co-payments at the time of service, as well as your payment for care not provided or coordinated, including paying for your deductible.

As a healthcare practice, our commitment and priority is to provide you the care, treatment plan, counseling and understanding you require in our medical opinion. As a courtesy, we’ll file your claim for you, but any responsibility you might have is decided by your insurance company and your benefits. If we verify eligibility or plan benefits for you, this is still not a guarantee of coverage.

Only when the claim is filed will the insurance company make a decision on how it will be paid–based on the information both on the claim and in your plan.

Here are some terms to help you understand your benefits:

Office Visit
A face-to-face meeting between a physician or other healthcare professional and a patient. Your portion (patient responsibility) is usually a co-payment and deductible, if applicable.

Procedure
An activity directed at or performed on an individual with the object of improving health, treating disease or injury, or making a diagnosis. Patient responsibility is usually deductible and/or coinsurance.

Covered Charges
(or Covered Benefits) – Services that are typically covered under the terms of your contract with your insurance company. It is important to note that even those services may be covered charges, they are often subject to your deductible and coinsurance.

Non-covered Charges
Services that are not covered benefits under the provisions of your insurance plan. If your insurance does not cover a service, you may be liable for the entire amount.

Contracted Rate
The negotiated amount an insurance company has agreed to pay a provider for specified services subject to copayments, deductibles, and coinsurance amounts.

Fracture Care
A 90 day global period during which a physician doesn’t charge for an office visit. The global period does not include X-rays, MRIs or CT scans.

Deductible
Almost every plan has a deductible. This is the amount the policyholder/patient must pay out-of-pocket before the insurer begins to pay benefits. In many plans, an office visit will not be subject to the deductible and the only cost-sharing is a co-payment. Procedures are always subject to the deductible.

Co-payments
A specific charge that your health insurance plan may require you to pay for a medical service or supply. For example, your plan may require a set fee for an office visit–typically ranging from $10-$100. Many policies have a higher “copay” to see a specialist vs. a primary care physician.

Coinsurance
The amount that you (or a second insurance) are obligated to pay for covered medical services after you’ve satisfied any co-payment or deductible required by your health insurance plan. This is typically represented by a percentage of an eligible expense that you are required to pay. For example, an 80/20 plan means the insurer pays 80% of the contracted rate on procedures, while the insured will pay the remaining 20% of the contracted rate.