INSURANCE PARTICIPATION POLICY

Due to pressures exerted upon our practice by malpractice insurance companies, the government and health insurance companies, we were forced to make some difficult decisions. In order to continue to provide the highest quality care, we have chosen not to participate in managed care companies which constrict our ability to function in an optimal medical environment. We still accept patients from all insurance companies offering out of network benefits (See below). We can accommodate almost anyone and wish to deal directly with the patients rather than the insurance providers. The following explanations and definitions may help you better understand your insurance coverage.

Indemnity Insurance. With this type of insurance, there is no network of participating physicians and the patient is free to seek care from any physician the patient chooses. Typically, these products have a deductible that must be met before the company reimburses the patient. After the deductible is met, the patient is responsible for a portion of the subsequent charges, most commonly 20% – 30% of the usual and customary charges, up to a certain maximum out of pocket yearly expense.Once the insured meets the maximum out of pocket expense, the insurance covers all other expenses 100%.

Managed Care HMO (Health Maintenance Organization). This is a type of insurance where there is a network of physicians that participate with a given insurance company. The patient is responsible for small co-pay at the time of services. If a patient seeks care with a physician outside the network, the patient will most likely be responsible for the entire physician’s bill and the insurance won’t cover any of the costs. However, some HMO’s have “out of network benefits” (See Below), in which case some of the costs may be reimbursed by the insurance company.

Managed Care PPO or POS Plans (Preferred Provider Organization or Point of Service Insurance).These plans are a combination of the above mentioned types of insurance. Typically, there is a network of doctors that participate with the insurance company and if the patient seeks care from one of these physicians, the insurance works as an HMO and the patient is responsible for only a co-pay. However, as opposed to the strict HMO products, the patient with a PPO or POS product has “Out of Network Benefits”. This means the patient has the freedom to seek medical care from a physician who is not in the network, such as our physicians, and the insurance then functions exactly as an indemnity plan described above. Bear in mind that the deductibles, co-insurance and maximum yearly out of pocket expenditures vary from insurance to insurance, and plan to plan.

Medicare.Allied Surgical participates with Medicare. Patients are typically responsible for a deductible and 20% co-insurance up to a certain maximum within the fee schedule imposed upon us by the Federal Government The patient is not responsible for any amount above the Medicare fee schedule. By participating with Medicare, we accept a reduced fee schedule in the order of a 66% discount to our usual fees. We have agreed to do so because we feel an obligation to assist seniors and retirees on a fixed income obtain access to medical care at a time in their life when their financial situation may be precarious and the possibility of health problems may be greatest. However, by federal law as well as by virtue of the fact that we are already providing services at a great discount, we are unable to write off deductibles and co-insurance except in cases of financial hardship.

The Issue of Usual and Customary. Insurance companies calculate the percentage a patient has to pay based on what they consider to be the “Usual and Customary Fee”. At Allied Surgical we have gone to a great deal of trouble to set our fees within the “Usual and Customary” range. We would be happy to provide you with the national reference source we use to set our fees. Should our fee exceed what the insurance company considers to be “Usual and Customary”, we will provide you with guidance on how to appeal their determination. In general, we have found that the majority of times our fees fall within the Usual and Customary guidelines of the insurance industry.

Financial Aid.For generations physicians have provided services to those who can’t afford to pay for medical care at reduced rates or even pro-bono. We continue with that tradition at Allied Surgical Group. For patients who need financial assistance, we will provide services on payment plans and if the financial hardship is great, we will provide services at reduced fees or even free of charge for the most serious situations. Documentation may be required, but if you have a special need, please bring it to the attention of your doctor or our billing staff.

Final Note.Over the past 10 years, the demands placed on our practice by the insurance industry have become more than we can bear. We are facing increasing regulations, restrictions and bureaucracy, increasing practice overhead costs and skyrocketing malpractice costs while at the same time facing decreasing reimbursement by the insurance companies. We understand that our dropping out of all networks affects our patients and referring physicians, however, our practice was being placed in an untenable situation. We provide the best surgical care in the area and invite you to visit our web site to familiarize yourself with our services. We apologize for the inconvenience and expense this represents to you, but hope you understand our situation.