Insurance and Billing

The health insurance process can be confusing. Here are some basic facts and tips to help you better navigate the insurance “system”.

How health insurance works

Most individuals with health insurance typically receive it through their employer. In recent years, premium costs for insurance, as well as out-of-pocket costs for deductibles and co-payments have risen dramatically. The total increase in healthcare spending has led to a national debate over how to control costs and provide coverage for the uninsured. Though the system needs significant reform, here are some key points to remember:

We at The Noe Valley Clinic have designed a more efficient delivery system to take better care of you
Since health insurance companies only pay for direct office visits, our small annual membership fee helps to cover the costs of providing online/email services that you won’t find in other medical practices
Insurance companies have created many rules to try to keep costs down. Though these rules may sometimes be beneficial, it is impossible to keep track of all of them. Every plan has different rules, and there are hundreds of health plans. Because of this, we ask that you try to learn more about your own insurance plan and what is covered/not covered. This is best done by calling the number on your insurance card.

Key insurance terms

Here are some key definitions that you might find helpful:

HMO (Health Maintenance Organization): This form of insurance offers you comprehensive coverage among a more limited selection of providers. Visits to specialists often require referrals, and diagnostic tests, procedures, and specific medications may require approval in advance. Out-of-pocket costs are generally lower than other forms of insurance, but monthly premiums are usually higher. In San Francisco and Marin, we offer HMO services through the Brown and Toland group.
PPO (Preferred Provider Organization): This type of insurance gives you more flexibility in who you can see. But it often costs a bit more. Most PPOs charge you based on your level of consumption. Deductibles, co-insurance and other charges are common. In addition, we’re finding that PPOs have an increasing number of restrictions on which medications we can prescribe you.
POS (Point of Service): A POS insurance plan is a combination of PPO and HMO. You have the flexibility of both HMO and PPO coverage, but are charged depending on who you see. These plans are functionally quite similar to PPOs but can sometimes be a little cheaper.
HSA (Health Savings Account): This is a new form of insurance that’s becoming more popular in some parts of the country. It essentially moves the full burden of costs to you, the patient. If you don’t spend any money on health care, you get to save the money in a special tax-free account. If you do utilize any health care services, you pay for the full cost yourself.
Deductible: This is the amount that you are required to pay before your insurance kicks in. We’re finding that this number is going up as employers are less willing to pay more for health care costs.
Co-Insurance: Some health plans are structured so that you pay a percent of your health care bill, often ranging from 10-50%. Similar to a deductible, this amount is pre-specified by your individual health plan.
Co-Payment: This is the amount that you pay us when you come in for a visit. If you are an HMO patient, it’s the only amount we receive for your visit. If you are a PPO patient, it’s a form of pre-payment.

For more definitions: http://www.insurelane.com/health/glossary.html

How billing works

If you have HMO insurance, your billing is fairly straightforward. You pay a co-payment upon your visit. And that’s usually all you owe.

If you have PPO insurance, it’s a bit more complicated. Here’s an example to illustrate:

you visit your physician and pay a co-pay of $20
the physician charges $200 for the visit and submits a claim to your health insurance company
the insurance company approves the visit at a price of $140
if your deductible is higher than $140, the entire amount is charged to you, the patient
if your deductible amount has already been covered, the insurance company pays a portion of the $140 depending on the specific rules of your plan (for example $60) and the remaining balance is charged to the patient ($80)
in both cases because you already paid a co-pay of $20, your invoice would reflect this amount in your balance due

The Noe Valley Clinic