Health Insurance Co-Pays, Deductibles and Pre-Certification
We at Parkway Ambulatory Surgery Center (PASC) understand medical billing and insurance statements can be difficult to understand. Our billing department can review with you the insurance issues, charges and reimbursements.
PASC is committed to make your choice to have surgery in our facility as painless as possible. We don’t want financial issues getting in the way of your recovery.
At PASC, we will assist in maximizing your insurance company payment to you for your healthcare costs. To help you understand your healthcare costs, below is a brief outline of various terms and steps.
There are many qualifications and limitations regarding what health insurance covers and to what extent. Certain requirements must be satisfied, which means paid by or on behalf of the insured, before the insurance company will begin to pay for your medical care. For example, all co-payments (co-pays) and deductibles must be paid out-of-pocket first.
What Is a Co-Payment?
A co-pay or co-payment is the contractual amount you must pay for your use of a specific medical service covered by your policy.
Understanding What Qualifies or Limits Your Benefits
Make a note of all of the potential ways that either qualify or limit your benefits.
Understanding How Insurance Companies Determine Deductibles
The second requirement that must be satisfied before the insurance company will consider paying any insurance benefits is the deductible. The deductible is an amount you must pay for your medical bills in addition to your co-payment before the insurance company will begin paying benefits.
Understanding Failure to Pre-Certify Treatment Deductible
Another type of deductible often used by insurance companies is a failure to pre-certify treatment deductible. This deductible, in addition to the calendar year deductible, is another amount of covered expenses you must incur before any benefits are payable under the policy, but this is only triggered when you fail to get the insurance company’s approval prior to treatment.
This certification is required prior to all ambulatory / hospital inpatient admissions, except in an emergency situation. In essence, you are asking the insurance company for permission before you get the treatment you need. In some cases, the insurance company may even ask you to get a second opinion as to the appropriateness or medical necessity of the surgery. If they do, it will be at their expense.
Is Pre-Certification a Guarantee of Payment of Benefits?
Pre-certification is a requirement, but not a guarantee of payment of benefits. All of the other policy provisions still apply, some of which may have the affect of limiting the amount of benefits payable, even thought the treatment was pre-certified.
Understanding Your Out-of-Network Benefits
Insurance carriers classify Parkway Ambulatory Surgical Center (PASC) as an out-of-network facility. Most ambulatory surgery centers and hospitals have made the same choice.
This does not mean that we do not accept your insurance, rather, it means that we do not currently have a contract with your health insurance provider. However, if you have an insurance policy with out-of-network benefits (i.e., a PPO policy), you have the additional benefit of visiting physicians and surgical facilities that are outside of your insurance carrier’s network.
What Kind of Bills & Statements Can I Expect After My Surgery At PASC?
After your surgery you will receive a statement called an Explanation of Benefits (EOB) from your insurance company. It itemizes the fees charged and indicates the allowable amount covered by your insurance company. Sometime after that, you will receive separate bills from PASC, your surgeon, and your anesthesiologist for your surgery.
What if I have concerns paying the bill?
In the event that you have difficulty paying your bills, our billing staff will assist you with any financial arrangements. We can offer a wide range of payment options and resources for financial assistance.