About Medical Billing…
At Altitude Family & Internal Medicine, we understand how complicated and confusing medical billing process and the statements you receive may seem. This section will hopefully help you have a better understanding of the medical billing process, and answer common questions that you might have.
The U.S. Department of Health and Human Services (HHS) through the Centers for Medicare and Medicaid Services (CMS) in association with the American Medical Association (AMA) establish and publish coding regulations used by Medicare and private insurance carriers to process medical claims. Altitude Family & Internal Medicine follows these published guidelines when it submits claims, and this may affect your bill.
Will you bill my insurance company for my visit?
Yes. We are happy to bill your insurance company for the services you receive as a courtesy to you. As a courtesy, we will file all claims for our service with your primary insurance company. If you have secondary insurance, we will automatically file a claim with them as well. Once we know your insurance has paid in full on their portion of the bill, the remaining balance of the bill will become the patient’s responsibility and accordingly an invoice will be sent.
Alternatively, you may pay your balance in full and then submit the claim to your insurance company for reimbursement.
Services billed on your behalf are provided to you on credit, with no guarantee your insurance will cover any or all services provided. Please be advised that the ultimate financial responsibility for services provided does not belong to your insurance company, but to the person receiving the services or their guardian.
Your medical insurance policy is a contract between you and the insurance carrier. Altitude Family & Internal Medicine is not a party to that contract. Your coverage, the requirements for pre-authorization, pre-certification, specialist counseltation, deductibles, co-payments and co-insurance are all defined in your policy. You are responsible for reading, understanding, and following the procedures outlined in your policy handbook. We will be happy to assist you when and where we can with specific questions and concerns. Your employer, insurance agent, or the federal government determines the range of benefits eligible to you.
Why do I have to pay a copay at the time of service?
Our policy regarding the collection of copays is based on federal regulations established by the U.S. Department of Health and Human Services, as follows…
“It is unlawful to routinely avoid paying your copay, deductible or coinsurance payments… even if your doctor allows it. Unless you complete a “Financial Hardship” form and qualify for financial assistance under Federal Standards, you may NOT routinely evade paying your responsibility portions for medical care as outlined in your insurance plan even if your doctor allows it. You both may be charged for breaking the law. This includes services deemed as “professional courtesy” and “Take what insurance pays”. Failure to comply places you in violation of the following laws:
Federal False Claims Act
Federal Anti-Kickback Statute
Federal Insurance Fraud Laws
State Insurance Fraud Laws.
Failure to comply may result in civil money penalties (CMP) in accordance with the new provision section 1128 A(a)(5) of the Health Insurance Portability and Accountability Act of 1996 [section 231(h) of HIPAA]. Exceptional cases do apply.
For more information regarding this, please contact the Office of Inspector General, U.S. Department of Health and Human Services.
How can I pay my copay?
Altitude Family & Internal Medicine accepts cash, major credit cards, and debit cards. We can also keep your credit card on file in our secure system.
Why did my bill arrive so long after the time of service?
This is an area where unfortunately we are both victims of “the system.” Typically your claim will be sent from our office within one week of your appointment, and if everything goes smoothly we expect to receive a reply from your insurance company within 60 days. Given the current complexity of the billing process, however, the claim submission process can take up to 90 days, and the insurance response process may take up to an additional 90 days. When there are unexpected problems with the claim, this time can double. This process will also take longer in cases where there is a secondary insurance to bill. Be assured we will do everything in our power to expedite this complicated and sometimes time consuming process.
Why might my medical provider charge for two services at one appointment?
By law, medical providers must accurately specify the type of treatment they provide to a patient, whether preventative, problem-related, or procedural in nature. Health insurers base their coverage determinations from the procedure and associated diagnosis code(s) submitted for claims processing.
Federal guidelines specify that a provider must code and charge for preventative care, such as an annual physical exam, separately from problem-related care (i.e., sprained ankle, cough, or high blood pressure), or from procedural care when the services are performed at the same visit. For example, if you receive treatment for a specific health problem during your physical exam, your physician is bound by established coding regulations to submit a separate code and charge for this service. Please be assured that in these circumstances the quality of care you receive will not be affected.
Why can't these two services be combined if they occur during one appointment?
According to the regulations, these services cannot be combined because they are not the same service and are considered unrelated. Most health insurers also abide by these same regulations and consider preventative care and problem-related treatment to be different services. They are therefore willing to pay for these services separately.
In all cases it is important for you to understand your insurance policy or to check with your insurer prior to your visit to find out specifically what your insurance covers. Some insurance carriers, especially Medicare, have strict limitations regarding coverage for preventive services. The patient, his/her employer and the health insurance carrier are the only ones who know or can verify specific insurance coverage. Please realize that our medical providers and business office staff do not have access to this information.
What are the basic differences between a physical exam and an office visit?
A physical exam is a preventative health maintenance exam during which your physician evaluates your overall health by taking your relevant medical and family history, asking pertinent screening questions, and performing or ordering appropriate screening tests based on your age, gender, and medical risks. A problem-related office visit addresses a specific health problem through discussion, examination, diagnosis and/or testing, and treatment is prescribed as necessary.
Is charging for two services at one appointment a standard, ethical and legal practice in health care?
Yes. Legally, it is defined as a correct physician billing practice by CMS, which was established by HHS. The AMA guidelines also define this as a correct billing practice. Ethically, providing both services during one appointment uses your time and your provider's time more effectively and generally means that the problem-related office visit may be charged at a lower fee than if it were provided at a separate visit. It is always a significant time-saver for you and can also be a significant cost-saver for the patient since often only a single office-visit copay would apply as opposed to the two office-visit copays that would apply if the services were provided at different appointments.
This is a nationally recognized standard practice for medical billing and coding.
Why was I billed for a “nurse visit” when I never saw a nurse?
You are probably looking at code 99211, which many of the insurance companies inappropriately label as a “nurse visit.” In reality, there is no such thing as a “nurse visit.” Code 99211 represents an “office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician” as defined by CMS and the AMA. This is the appropriate code for us to use when you are seen in the office for a minor issue that does not require direct contact by a medical provider.
Why was I billed for “surgery” when I never had surgery?
This is another case of mistaken identity. Often the insurance companies will label any procedural code as “surgery.” In reality, the service performed may have been something to the contrary such as splinting of a sprained ankle, freezing of warts, or even a hearing test. We have no control over how the insurance company chooses to label things, but be assured that we are using the appropriate codes and following the established coding guidelines.
What should I do if I notice an error in my bill?
We certainly apologize for any errors that may have occurred on our end. We employ multiple levels of error checking to prevent errors in medical billing, including training our providers to expertly code, using electronic medical records, employing certified professional coders to review claims, using the latest claims auditing software, and submitting claims electronically. Medical billing has become so complex that even with all these systems in place, periodically there will be an unintentional error. Please use the contact information below to notify us if you think there is an error on your account.
What if I have further questions about the services I am receiving?
Billing questions and concerns should be addressed with our patient accounting department, who may be reached at (303) 730-2167. If you have additional questions, your medical provider will be happy to answer any questions about the services you are receiving.