Insurance Plans & Benefits
Sugarloaf Medical PC participates with most insurance plans with limited exceptions. Each insurance plan has different benefit packages and regulations, and it is impossible for Sugarloaf Medical to know all insurance packages and/or to verify benefits for each patient. Patients should be familiar with their insurance benefits, including policy coverage for the copay, deductible, and co-insurance amounts. Patients should advise Sugarloaf Medical’s staff regarding their insurance coverage for the services provided. Patients will be fully responsible for charges for services that are not covered by their insurance policies.
Patient Payment Agreement and Failure to Pay
Sugarloaf Medical PC is a member of the Emory Healthcare Network, and unless otherwise indicated, the insurance allowable fee for service is based on the Emory Healthcare Network fee schedule. You are responsible for keeping your account in good standing with Sugarloaf Medical. If you are unable to pay and a special payment arrangement has not been made, Sugarloaf Medical may deny you services or dismiss you from treatment entirely.
Payment Method
Sugarloaf Medical PC accepts personal checks, cash, MasterCard, American Express, Discover, and Visa. Checks should be made payable to Sugarloaf Medical, P.C. If your check is returned for any reason, a $30 service charge will be charged to your account. If payment by check is unsuccessful, Sugarloaf Medical PC may require you to pay for all future visits by cash or credit card.
Insured Patient Policy
At each visit, unless you are a Self-Pay Patient, you will present an active insurance card to Sugarloaf Medical. Sugarloaf Medical will file the insurance claim(s) with your insurance carrier for the services it provides you (reported as CPT (current procedural terminology) codes). Most insurance plans allow Sugarloaf Medical to bill for laboratory and diagnostic services it provides with few exceptions. If an exception applies, you will be billed directly from LabCorp and/or radiology facilities.
Your insurance claim will include the office visit code and all diagnostic testing performed including laboratory and other diagnostic tests as well as applicable codes for the administration of vaccines.
Annual Preventive Visits / Physicals are usually filed with the preventive visit code and laboratory testing and vaccine administration codes. Some screening laboratory and diagnostic testing performed during an Annual Preventive Visit / Physical may not be considered preventive by your specific insurance plan.
If you have chronic conditions (such as hypertension or hypothyroid) and/or have an acute problem to be managed (such as upper respiratory infection) during the Annual Preventive Visit / Physical, an office visit code will also be added to the claim in addition to all associated non-preventive diagnostic testing performed.
CPT codes for Annual Preventive Visits are often covered one hundred percent by a patient’s insurance carrier. Other associated preventive diagnostic testing (laboratory and ECG) and additional non-preventive services performed (such as management of chronic disease) may not be covered one hundred percent, and co-pays, co-insurance, deductibles, and/or other payments may apply.
You are responsible for the payment of co-payments, deductibles, and co-insurance amounts as determined by your insurance carrier within thirty (30) days of receiving a billing statement from Sugarloaf Medical PC. Delinquent accounts will be transferred to a third party collections agency, Transworld.
Once the insurance carrier processes the claim(s), it will usually send an Explanation of Benefits to you and to Sugarloaf Medical explaining the claim benefits process, including the physician payment and patient payment responsibility portion (more details on Explanations of Benefits below). If you feel that your insurance carrier made an error or if you disagree with their adjudication of the claim, please contact your insurance carrier directly. We will only bill you for what your insurance carrier determines to be your responsibility. If your insurance coverage changes, please notify Sugarloaf Medical as soon as possible to avoid issues for untimely filing of insurance claims. If you give incorrect information regarding your insurance coverage, or if your insurance changes or is expired at the time Sugarloaf Medical provides services, and/or there is a timely filing denial resulting in a denial of a claim, you will be responsible for the balance of the claim.
Insurance Claim Processing / Explanation of Benefits
An explanation of benefits (commonly referred to as an EOB Form) is a statement sent by your health insurance company explaining your policy coverage and YOUR PATIENT RESPONSIBILITY for the medical services provided. An EOB Form typically describes:
• The service performed—the date of the service, the CPT code and description for the service, and the name of the person or place that provided the service.
• The doctor’s fee, and what the insurer allows—the amount initially claimed by the doctor, minus any reductions applied by your insurance carrier.
• The amount the patient is responsible for in the form of copay, deductible and co-insurance. The patient responsibility portion is determined by your particular insurance policy.
• There is often a brief explanation of any claims that were denied, along with a contact to start an appeal.
Terminology
- Amount Billed – The full amount billed by your provider to your health plan.
- Your Plan Discounts (Adjustments) – This section details the amounts that you do not need to pay.
- Amount Paid by Your Health Plan – The portion of the charges eligible for benefits minus your copay, deductible, coinsurance.
- Copay – A set amount you pay for certain covered services such as office visits or prescriptions. Copays are usually paid at the time of service.
- Deductible – Your deductible is the amount you need to pay each year for covered services before your plan starts paying benefits.
Example: If your plan has a $2,000 annual deductible, you will be expected to pay the first $2,000 toward your healthcare services. After you reach $2,000, your health insurer will cover the rest of the costs. - Coinsurance – A percentage of covered expenses that you pay after you meet your deductible.
Example: Your plan might cover 80 percent of your medical bill. You will have to pay the other 20 percent. The 20 percent is the coinsurance. - Amount Not Covered – The portion of the amount billed that was not covered or eligible for payment under your plan. Examples include charges for services or products that are not covered by your plan, duplicate claims that are not your responsibility, amount related to not getting a pre-approval for services, and any charges submitted that are above the maximum amount your plan pays for out-of-network care.
- Your Total Responsibility – This section details the portion of the bill that is your responsibility to pay. This amount might include your copay, deductible, coinsurance, any amount over the maximum reimbursable charge, or products/services not covered by your plan. If you received payment intended for a provider, it is your responsibility to pay the provider.
- Claim Notes – When present, these notes provide general information about the claim and may also provide specific explanation of activity that occurred in the Amount Not Covered, Amount Paid by Another Source, and What Your Plan Paid fields. For example, if the claim was denied because your provider submitted the same claim twice, a note would tell you that the claim was denied as a duplicate.
- Network Provider/In-network Provider – A healthcare provider who is part of a plan’s network.
- Non-covered Charges – Charges for services and supplies that are not covered under the health plan. Examples of non-covered charges may include things like weight loss management or psychiatric treatment. Consult your plan for more information.
Your Patient Responsibility is invoiced to you based on the EOB Form provided by your health insurance company. If you feel that there is a mistake or insurance should pay for your services and would like to appeal Your Insurance decision, contact your insurance carrier directly to appeal their decision. Please note that COVERAGE DOES NOT MEAN PAYMENT.
Self-Pay Patient Policy
Patients who do not use insurance to pay for their treatments at Sugarloaf Medical are considered Self-Pay Patients. Prior to each visit, Sugarloaf Medical will give Self-Pay Patients an estimate for the visit based on the visit type and complexity of the visit. The estimate will be based on discounted prices and as a Self-Pay Patient, you must pay this amount prior to the visit. If a Self-Pay Patient receives additional testing and/or treatments not contemplated by the estimate, Self-Pay Patients may be required to pay additional amounts at the time of the visit. If Self-Pay Patients are unable to pay Sugarloaf Medical for additional testing and/or treatments at the time of the visit, Sugarloaf Medical will bill the Self-Pay Patients the full amount of the treatments provided at Sugarloaf Medical’s standard rates (based on the Emory Healthcare Network fee schedule).