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
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.
Suite 2G 
