What is a Co-Pay?

When services are NOT covered 100% by an insurance carrier, part of the expense is paid for by the patient.

How Much is the Co-Pay For This Service?

Generally the co-pay amount for a primary payor is in the form of a percentage or fixed dollar amount of the total allowable charge for that particular item or service. In the case where the patient has a Medicare coinsurance policy the co-payment amount is after Medicare pays 80% of the total allowable charge for that particular item or service. If the coinsurance carrier pays only part of the 20% after Medicare, then the remaining balance is the patient's responsibility.

What is a deductible?

The deductible is the amount of co-payment you are required to pay before Medicare or any insurance carrier. The deductible is usually set to zero at the beginning of every calendar year. However, if you don't have any claims until later in the year, you should expect to receive a deductible bill for the first claim(s) submitted to Medicare for that calendar year. Your particular secondary insurance plan may not cover the Medicare deductible and therefore is your responsibility to pay the provider.

NOTE: Medicare will NOT allow a provider to waive a deductible bill.

Why do my invoices come so long after the actual date I receive the service?

Sometimes it can take up to six months after the initial date of service to gather all of the documentation needed to submit a claim to your insurance carrier. During that time any one of the following could occur..

• If the Doctor doesn't sign the Certificate of Medical Necessity immediately, which can take 15 days
• If Medicare rejects the claim because certain information is missing, which can take 7 days
• If the claim needs to be resubmitted, which can take 14 days
• If the claim needs to be reviewed, which can take 45-60 days

Remember, that the provider is not charging you at the time of delivery (because you have coinsurance that may cover the co-payment) and when the provider gets paid they have incurred many expenses involved with the product/service that was provided in good faith to you.

NOTE: The claim can be submitted as late as 15 months after the date of service at which time the patient is still responsible for the payment of any coinsurance and/or denied products/services.

Can an invoice be paid with a credit card?

Yes, ask your provider if they accept credit card payments, or look on their information packet (or any paperwork from them) that you received.

Does my Insurance cover this?

First ask your provider if they accept the insurance plan that you have (i.e. Medicare, Major Medical, HMO, etc.). Then, do one of the following:

For a Commercial Insurance Carrier, you should first verify that the specific product ordered is covered. When calling, ask if the product (give the name) is covered?; Do you follow Medicare coverage guidelines? (If so, then see the Medicare Screening List); Do I have a co-payment with this product?; What is the maximum amount (or rental period) that you will pay for this product?

For Medicare, if the product meets the coverage criteria (See Medicare Screening List), the paperwork is gathered to provide information to Medicare and the product has not been purchased recently for the patient (or some other unforseen disqualifying information) then Medicare should pay for the product/service (and the deductible would be your responsibility).

If you have a Medicare Secondary Insurance, you should verify that the specific product being ordered is covered. When calling, ask if the product (give the name)is covered?; Do I have a co-payment with this product? Do you cover the Medicare deductible?; What is the maximum amount (or rental period) that you will pay for this product?

What do I do if my Doctor has not signed the Certificate of Medical Necessity?

If you have paid for a product (because the provider did not take assignment) and the doctor has not (but should) filled out the Certificate of Medical Necessity, then you should get another copy from the provider and make an appointment to deliver the Certificate of Medical Necessity to the doctor (or staff) and wait while they fill it out (or tell them you will be back tomorrow to pick it up).

NOTE: When getting the Certificate of Medical Necesity (CMN) filled out it is permissible to have a doctor's staff member fill out the CMN, but the Doctor must review and sign it.

Why do I get a bill if my co-insurance covers the product?

Do you have Federal Blue Cross and Blue Shield? If so, they will only pay the patient (not the provider) for the product/service. When you receive an invoice from the provider, match it up with the Explanation of Medical Benefits from your insurance carrier. Your provider can be paid with a check from you or your may sign the insurance carrier's check and write "Pay to the order of Your Provider" and mail it to them.