Rex Hospital Area (919) 782-9005
North Raleigh (919) 781-2500

Insurance & Billing Information

Basic Information

Our office is in network with most major insurance plans. When you present to our office you will need to bring your insurance card with you as proof of current coverage.  It is your responsibility to provide us with your accurate information & it is fraudulent to knowingly present invalid insurance information.  Please make sure you notify the staff of any changes in your insurance coverage as soon as possible.  We ask that you present your current insurance card at every visit because although you may think you insurance information is the same as it was at a previous visit, however that is not always the case.

For example, every July 31st the BCBS State Health Plan fiscal benefit year starts over and they typically send out a new card every year in June prior to this happening.  This past July 1st, 2013 saw a slight change in their benefits.  Even though the member’s covered by this plan did not make any changes and are they are still covered by the same employer in their mind they have not had a change in insurance when asked by a medical office employee for any insurance changes.  However, upon inspection of the new cards that were issued to all members in June 2013 for the upcoming year there is a noticeable change to the Subscriber ID Number.  This may not seem like a big change, but if the claims for services received starting 7/1/13 are not filed with this new Subscriber ID and are instead filed with the Subscriber ID Number from the previous benefit year then the claim will deny and kick back stating either “Invalid Subscriber ID” of “Patient Not Eligible”.  This causes delays in processing and payment for your services.

We will NOT file your insurance claims without a copy of your current ID card.  If you need medical services and you do not have your insurance card, you may still keep your appointment.  However, you will be asked to pay for services in full prior to being seen.  We will quote you the best estimate possible based on the reason for your visit; however it is not a guarantee that there will not be additional amounts due at check-out based on what was actually done during your visit.  All insurance companies have a deadline for claim filing and if you supply us with your insurance card within that time frame we will file your claim.  When the claim is paid, you will be reimbursed for any overpayment you made.  If we do not receive the information until after the claim filing deadline has passed, we will not submit the claim, therefore you will not be able to get any reimbursement from us for your visit.

It is your responsibility to notify us in a timely manner of any insurance changes.  Ultimately you should notify us prior to checking in for your appointment, or even on the phone when scheduling so we can make a note of the change to ensure we ask you for the updated information.  All insurance companies have a limit on the amount of time we have to file a claim;  for example Cigna claims cannot be filed more than 90 days after the date of your visit, United Healthcare gives us 6 months, but some UHC plans give us as little as 45 days.  Since it is your responsibility to give us the correct information you are the one held accountable if you do not furnish us with the correct information to be able to file your claim within that time limit and you are responsible for the entire charged amount.

Double Insurance Coverage

If you are covered by two plans, usually you are the subscriber for one and a dependent on the other plan.  The plan for which you are the subscriber is your primary carrier.  By law, your claims must be filed with it, before submitting them to your secondary plan.  You do not have the option of designating your secondary plan as primary and it is fraudulent to conceal the existence of a primary plan from a secondary one.  We typically only file claims directly to primary insurance plans.  Regardless of your secondary coverage you are responsible for any balances due after your primary insurance company pays.

Out-of-Network Coverage & Non-Covered Services

While our office has contracts with most of the major health insurance carriers, that does not guarantee that our practice is contracted with each individual plan those carriers offer.  It is ultimately your responsibility to check with your insurance company prior to your visit to verify that we are listed with your plan as in-network providers.  Due to the volume of available plans currently in the insurance market, we are unable to know the coverage offered by each of these plans.  We will do our best to keep you as informed as possible based on current information our practice has been given by each insurance carrier, but we cannot be held liable for services you receive that are processed as either out-of-network or non-covered by your individual plan.

If we are not contracted with your specific insurance plan, it is our office’s policy that payment is due at the time services are performed.  We will gladly provide you with an itemized form of your charges that you can use to file a claim to your insurance company with.  Also, keep in mind that if we are not contracted with your insurance company we are not held by their negotiated rates and you therefore may not be reimbursed 100% of what you paid by your insurance company.

Co-pays, Co-Insurance & Deductibles

We are required by your insurance plan to collect co-pays on the date of service.  This will be collected upon check-in along with any other balances owed on your account.  Failure to do so will result in your appointment being rescheduled to the next available open appointment time on another day except in the case of emergent medical situations.  We also reserve the right to notify your insurance company if you fail to pay your co-pay, and other “out-of-pocket” charges, such as deductibles and/or co-insurance which is a breach of your personal contract with your insurance carrier and may result in your insurance company terminating your coverage.  For your convenience we accept MasterCard, Visa, American Express & Discover.  We also accept Cash and Personal Checks.  We do process all of our checks electronically with Telecheck.  If your check payment is declined you need to be prepared to make alternative payment and contact Telecheck to find out why it was declined, we do not have access to that information.

Annual Examinations vs. Problem Visits

As a commitment to your health, our physicians recommend that every patient have an “annual exam” that enables them to evaluate your overall health and make sure you are not developing any unexpected problem or illnesses. Unless there is a major new finding, or a significant medical problem which must be addressed, we must submit the service to your insurance company as a routine, annual or preventive examination.  Your “annual exam” consists of three parts; the office visit portion of the visit, the Pap smear, and the pelvic and breast exam and is billed to your insurance this way.  It is your responsibility to check with your insurance carrier to check your coverage for these services.  Not all insurance plans cover all three portions of the exam and therefore will be your responsibility.

Your physician may recommend that screening tests are performed during your annual exam. Despite being recommended by your physician, it is possible your insurance will not consider them medically necessary, even if a positive family history for a condition exists. Most insurance plans have specific guidelines for coverage of screening tests and if your insurance determines the tests to be non-covered, you will be responsible for paying for them. The tests cannot be submitted as anything other than screening, unless you have specific, documented symptoms on the date of service that warrant the test. Even if the results of these screening tests show some problem, if they were done for screening purposes they must be submitted that way to your insurance company, and we cannot change the information on the claim for payment purposes.

If there is a new problem discovered during the exam that requires attention, or a significant medical problem requiring additional time and/or decision making on the part of the physician, there will be an additional charge for addressing the problem. You have the option to tell the provider that you do not wish to address any issues outside of the wellness exam.  If you choose to combine your annual wellness exam with a problem visit to discuss any issues found during the exam, any pre-existing medical problems or any non-gyn related health problem that you choose to have us manage for you instead of an outside primary care physician there will be an additional charge for those services rendered.

The annual exam itself cannot be filed as problem related and will be filed as routine. The additional charge will be filed as problem related, with the appropriate diagnosis for the problem. It is extremely likely that your insurance company will determine that you are responsible for two co-payments in this situation; one for the annual exam and one for the problem. You are responsible for payment of any portion of your charges not paid by your insurance (excluding contractual write offs) including, but not limited to, two co-payments, if applicable.  We have no control over how your individual insurance company and chosen policy choose to process your claim and assign patient responsibility.

We understand that sometimes it is not possible or convenient to return for a separate visit to discuss these additional issues and our providers are concerned about your health care above anything else.  Therefore they are more than willing to take care of all of you needs during you wellness exam instead of causing an inconvenience by asking you to return for a separate visit for your problems.  However, we must file those diagnosis codes to your insurance company along with your wellness visit.

We understand that many insurance companies are now offering 100% coverage for wellness visits and you may have only intended to come in for a routine wellness visit because of this coverage; however if you choose to have any additional problems addressed you may be responsible for a portion.  These charges are not considered part of your wellness visit, even though it was handled during your wellness visit.