Understanding Your Health Insurance

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.