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billing
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Effingham,
IL 62401 
Dr. James Graham is a
proud member of the
Greater Effingham
Chamber of Commerce
& Industry
For
medical questions,
please contact us at graham@consolidated.net
For technical concerns
regarding this site,
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the webmaster.
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At your first visit our office will make a copy of your insurance card to keep in your file. Please make sure that you have your insurance card with you at your visit. If you are an established patient and have new insurance you need to have your card with you so that we can update your file and send the claims to the correct insurance company. It is your responsibility to make sure that we have the correct insurance information. If you have not received an Explanation of Benefits (EOB) from your insurance company and your medical bill is 4 weeks old you should contact your insurance company. The following information will be helpful the next time you have to contact your insurance company.
Please contact our office to verify that Dr. Graham is a provider for your insurance company. | Top | How Well Do You Know Your Plan? I have created a list of questions that you should be able to answer about your insurance coverage. If you do not know the answer to any of the following questions, you should contact you insurance company and review your benefit package.
How much
is your annual deductible? When does
your deductible start over? Is your
insurance company a PPO or HMO? Are you
required to use physicians listed in a preferred provider handbook? Do you have
a list of your coverage exclusions? This can be found in your
policy book. Do you need
to pre-certify scheduled surgical procedures? Does you
insurance require a second opinion on certain surgical procedures?
Do you have
a prescription drug card? | Top | Usual, Customary, And Reasonbale (UCR) Have you ever received an EOB from your insurance company informing you that your physician exceeds the usual and customary allowance? Did you notice that your insurance company will not pay the amount that they feel is above the usual and customary? If you had a minimal charge the amount is usually not much, but if they do this on a surgical bill it could be hundreds of dollars. You are responsible for the total amount that your provider billed even if your insurance company doesn’t pay the total amount billed. This situation is always very confusing because one insurance company might state that a physician is charging above UCR for a procedure while another insurance company is allowing full price for the exact same procedure. If you receive an EOB that states your physician is above the UCR you can contact your insurance company and ask if they will review your claim. If the insurance company agrees then you should contact your physician and ask them to send the requested information to your insurance company. Please keep in mind that you are responsible for the total bill even if your insurance company decides that they are not going to send an additional payment. | Top | New Patient vs Established Patient A new patient is one who has not received medical services from his physician (or any other member of the physician’s group in the same specialty) within the last three years. An established patient is one who has received medical services from his physician (or another member of the group of the same specialty) within the last three years. See also: Why was I billed for another new patient visit? and The Level of Your Office Visit Almost every insurance plan has exclusions. Make sure that you are aware of what your policy does and does not cover. This information should be listed in your insurance handbook. Tips:
If you are
not sure if something is covered, contact your insurance company
and ask. A customer service representative should be able to
answer your questions. Ask your
physician to provide you with the codes that will be used to
bill the insurance company. After obtaining this information,
relay the information to a customer service representative with
your insurance company. He or she should be able to tell you
if the services are covered. Always ask
the name of the person that you speak with at your insurance
company. This will prove helpful should your insurance company
not pay for a service despite their claim that it would be covered. If you have a billing question, click here to send an email to our office. | Top | Are Functional Orthotics Covered By My Insurance Plan? You should read the information listed below and then contact your insurance company to verify coverage.
| Top | If your insurance is a HMO or PPO you may have a copay amount listed on the front of your insurance card. When you visit a physician listed in your insurance company's preferred provider network, you are responsible for the copay amount at the time of the office visit. This is very cost effective. However, you must understand your insurance policy. This can also be very confusing! We often receive calls from patients informing us that they received a statement from our office. The patient states that there must be an error in our billing because he paid his copay at the time of the visit. The following list includes just a few reasons that you may be responsible for more than your copay amount. I hope that you find this helpful.
Once again,
I urge you to review your insurance policy book. If you have any
questions concerning coverage, contact your insurance company. By
understanding your insurance coverage you could save yourself time
and money. When
Medicare is the Secondary Payer Under specific
circumstances when beneficiaries are covered by other third party
payers Medicare can be the secondary payer. Medicare is secondary
to employer group insurance, certain health plans that cover aged
and disabled beneficiaries, worker's compensation, automobile, and
liability insurance. Please notify the physicians billing office
if Medicare is considered your secondary insurance. There will be
much confusion if Medicare is billed first. What To Do If You Receive A Check From Your Insurance
Company Some
insurance companies send payment for medical services to the patient
instead of the doctor. If you have already paid your doctor in full,
then you should cash the check. If you have not paid your doctor
you should:
I
have heard of situations when the patient received the check from
the insurance company and then didn’t pay the doctor. If
you receive a check in the mail from your insurance company I would
encourage you to contact your doctor’s office and make sure
that your account is paid so that there are no problems with your
account at a later time. The deductible
is the covered expense that the insured and each dependant must
pay before the insurance will make a payment.
If you do not
understand your yearly deductible, you should speak with a representative
from your insurance company and have him explain this in greater
detail. Time
for Insurance and Patient Billing This month I
received an e-mail with the following question: "Do physicians
or hospitals have a time limit for submitting claims to an insurance
company or sending a patient bill?" This person
received bills for a few months following her hospital stay and
heard nothing more so assumed all of the claims were paid. After
one year, she started to receive forms from her insurance company
as well as bills from the physician and hospital. Answer: No.
I am not aware of a time limit. I contacted a local hospital and
the billing department was not aware of a time limit either. Primary
VS. Secondary Coverage There can be
confusion concerning insurance coverage when the husband and wife
are both employed and each have a primary insurance plan. You will
need to determine which is the primary and which is the secondary
insurance. In most cases the subscriber’s or insured’s
insurance company is always primary for the subscriber. This means
that the husband’s insurance is primary for him and the wife’s
insurance is primary for her. Dependent coverage is determined by
the "birthday rule." The insured whose birthday comes
first in the year would be considered the primary insurer. EXAMPLE:
Husband’s birthday 11-13-71 In the above
example the wife would be the primary insurer. This is because the
wife’s birthday comes first in the year. The birth year does
not matter . If you have
questions about your insurance coverage you should contact your
employer and have them explain your insurance coverage to you. The
Level of Your Office Visit New
or Established Patient Each
time you visit your physician he/she must decide the level of your
office visit. This is determined by many factors, which include
medical history, examination, medical decision making, nature of
presenting problem, counseling, coordination of care, and time.
Your physician must meet certain criteria in each of the listed
categories. This can be very time consuming and usually requires
very accurate documentation. These are only
the office visit codes. There are many other codes that can be used
for hospital visits, emergency room visits, consultations, critical
care services, nursing home visits, and so on. Every code listed
above should have a different cost. The 99201 or 99211 should cost
least and the 99205 or 99215 should cost the most. If you have a
minor problem that does not require much care you would probably
be charged a level 1 or 2 office visit. If you have a medical problem
that has high severity and requires immediate medical care you would
probably be charged a level 4 or 5 office visit. If you have
questions about the level of your visit you should ask your physician's billing department. They should be able to answer any questions that you have. When you receive
a bill from a physician or hospital you should check it for errors.
If you find something on your bill that you do not understand you
should contact your physician’s billing department. The billing
staff should be able to explain the charges to you. The following
list will give you a few ideas of what you should look for on your
bill.
| Top | Understanding Your Explanation of Benefits (EOB) Your insurance
company should send you an Explanation of Benefits after consideration
of each medical claim. Understanding your EOB will help you make
sure that your insurance company has paid correctly. The following
items are typically what you would find on your EOB: Date
of Service - This is the date you were seen by your physician
or tests were performed. Amount
Billed - This is the amount charged for the services in
question. Not
Covered - This is the amount your insurance company will
not pay. You are responsible for this amount. Deductible
- This is the dollar amount that was applied to your annual
deductible. Patient
Co-Pay - This is the amount you would pay if your plan
requires a co-pay for services. (Co-Pay information is usually
listed on your insurance card.) Your co-pay is only effective
if you go to a provider listed in the insurance network. PPO
discount - This is used when you go to a provider in your
insurance company’s network. You should NOT be billed
for this amount. Covered
Charge - This is the amount that your insurance company
considers payable. Remember that your insurance will only
pay a percentage of this amount! Paid
at amount - This will show the percentage that your insurance
company has paid on your claim. (Example- 70% - 80% - 90%…) | Top | Why
was I billed for another new patient office visit? Why is a
new patient office visit more expensive than an established patient
office visit? If you have
questions about your bill you should always contact your physician’s
office for someone to explain the bill to you. | Top
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| NOTICE: All pages and their content are provided for information only. This information should not be used for medical diagnosis or treated as health care advice. Please seek the consultation of a qualified health care professional. | ||||
