BILLING


Who can I call prior to surgery if I have questions about the Estimated financial responsibility I was quoted?

Please call our Insurance Verification/Benefits Department at (949) 999-4501. Our representatives will be happy to assist you.

Whose responsibility is it to notify me of my benefits?

It is the patients’ responsibility to know their benefits and be aware of any authorizations or pre-certifications that maybe required prior to having their procedure. As a courtesy our Insurance Verification Department checks eligibility and benefits for all our patients, but they are limited to the information that is quoted to them by your insurance.

If you know of any insurance changes or change of employment that may affect your coverage it is your responsibility to contact us with this information.

Will my insurance cover my surgery?

Coverage varies and exceptions can apply. Please call your insurance company, plan administrator, insurance broker or benefits department (Human Resources) of your employer with any questions regarding coverage.

Do you accept my insurance company’s payment as payment in full?

Patients are responsible to pay for their deductibles, co-insurance, non-covered services and co-payment amounts as indicated by their insurance company policy prior to or at the time of surgery.

When will I know how much I have to pay when I check in for surgery?

We make an effort to contact our patients one week before surgery regarding their financial obligations. If we cannot reach you personally by phone, we will mail out a letter with the information. Please call us with any questions.

I have insurance why am I being asked for payment up front?

All patients are required to pay their ESTIMATED financial responsibility (co-pay, co-insurance, and/or deductible) on the day of surgery. Your ESTIMATED financial responsibility is based on benefits quoted by your insurance and is the portion that your insurance will not reimburse us. All ESTIMATED financial responsibilities are based on our contract with your insurance and not on billed charges.

I already paid the doctor, why are you asking me for more money?
 
When having surgery, there are multiple parties involved:  surgical facility (Orthopedic Surgery Center), surgeon, anesthesiologist and possibly an assistant. Each of these parties will bill your insurance separately as we are separate, individual companies. Your estimated responsibility, which is based on the scheduled procedure and benefits stated by your individual policy, for the surgical facility is required on the day of your procedure.  Should another medical provider submit their claim prior to us and your responsibility is less than what you paid, you will receive a prompt refund.

Do I need to pay for DME (crutches, braces, slings, ice wraps, post-op shoes)?

We are not a DME provider. If you surgeon orders DME for you to take home, you will be billed directly at facility cost.

What forms of payment do you accept?

We accept Cash, Check, MasterCard, Visa, Discover, American Express, Care Credit, Money Order and Cashiers Check.  Please be advised that if paying by check that we need your actual driver’s license and that all checks are processed through TeleCheck as a one-time Electronic Funds Transfer (EFT) and funds may be withdrawn from your account as soon as the same day you make your payment.

What if I can’t afford to pay all of my co-pay on the day of surgery?

Our regular policy allows us to break up your payments into thirds and have you sign a Promissory Note. One third is paid on the day of surgery and two subsequent payments are made at 30 and 60 days. If additional time is needed we also offer Care Credit. This is a medical credit card, which you may qualify for. Please contact our Billing or Insurance Verification Departments to discuss alternate payment plans.

What is a Promissory Note?

A Promissory Note is a legal contract where you are agreeing to pay a third of your estimated financial responsibility on the day of surgery and then providing us with either credit card information or post dated checks to charge or deposit at 30 and 60 days. Any additional charges (implants, DME, additional procedures, non-covered items, etc.) are due in a final 4th installment at 90 days.

How can I contact my Insurance?

If you have been requested to contact your insurance to check on the status of your claim you can contact them at the phone number listed on your insurance card.

Who can I call if I have questions about my bill?

Please call our Billing Department at (949) 631-7850. Our Patient Account Representatives will be happy to assist you.

Can someone other than me call to ask about my account?

Due to HIPPA regulations and privacy practices we are only able to discuss your account with either yourself or your spouse if they are considered to be financially responsible. For minors we can only speak with the parents or legal guardians. To assign another person, please mail or fax (949.515.4821) us a signed letter indicating who we can discuss your account with as well as what we can discuss.

What insurance companies are you contracted with? 

We are contracted with major insurance companies. We also will bill a non-contracted payer.

Will you bill my Secondry Insurance?

As a courtesy, we will bill your secondary insurance. Please be aware that any amounts paid by your secondary insurance will be applied to the outstanding balance established by your primary insurance and any remaining balance will be considered patient financial responsibility.

Will I receive an itemized statement?

The Center does not do itemized billing. We can supply your with an Account Ledger which will indicate the procedure and diagnosis codes billed to your insurance along with any payments received. Please contact our Billing Department at (949) 631-7850 and our representatives will generate one upon request.

When will I receive a statement?

You will receive your first statement as soon as 1 week after your procedure. This first statement is just to notify you that we have billed out your insurance and to indicate any co-pays you may have made on the day of surgery. After that, statements go out on a 30 day cycle to keep you informed of the status of your account and any outstanding balance due.

I am a Medicare patient why am I receiving a statement?

All patients regardless of type of insurance receive statements at regular intervals to keep them informed of the status of their accounts. We find this useful in helping patients keep abreast of any issues that may occur and getting them resolved quickly.

Does my bill cover the surgeon and anesthesiologist?

No, your bill is solely for the facility charges. Your surgeon and anesthesiologist will bill separately for their services. You would need to contact their offices directly with any billing questions you may have regarding their services.

Who else might I receive a bill from?

You will receive separate bills from your surgeon, anesthesiologist, Registered Nurse First Assistant (if one utilized), Pathology (if specimens taken) and Durable Medical Equipment Provider (if DME provided by them).

Why do I have a balance due when I paid on the day of surgery?

Amounts paid on the day of surgery are ESTIMATES only based on the procedure scheduled and your insurance benefits. Payment received on the day of surgery is never to be considered payment in full. The final amount due can not be determined until after surgery as implants could have been used, DME issued or alternate/additional procedures performed.

Why am I being billed for Durable Medical Equipment (DME)?

DME is ordered by your surgeon to assist in your recovery is not covered in our contracts with your insurance. All DME is considered patient responsibility and is billed to the patient at our cost. with zero mark up.

What does it mean if my account is in appeals? Will I need to make payments while I await the outcome?

If your account is in appeals it means that your insurance did not pay your claim correctly and we have resubmitted a written appeal to them providing supporting documentation to reprocess the claim. If you have a patient responsibility it will be noted on your statement. After you have met your responsibility your account will be on hold until the appeal issue is resolved with your insurance (periodic updates will be mailed). Please be aware this can take anywhere from several months to 1-2 years. Once the appeal is processed if your insurance has assigned any additional patient financial responsibility you will then receive statements for that amount.

How can I pay my bill?

You can pay your bill in person at our facility, by mail via check or by filling out credit card information on back of your statement or by phone with your credit or debit card. We accept cash, check, credit cards (Visa, MC, AMEX, Discover, Care Credit), money orders and cashiers checks. All of our checks are run through Telecheck as an electronic fund transfer and must be honored by your bank when first presented.

What happens if I overpay?

Once your insurance processes your claim correctly if overpayment is generated we will send you a refund. All refunds are done in the form of a check.

GLOSSARY OF BILLING TERMS

Claim-Form submitted to your insurance company for reimbursement that indicates all procedures performed and diagnosis.

UB92 vs HCFA- UB92 is the name of the claim form used by facilities for billing your insurance. HCFA is the name of the form used by facilities when billing Medicare or by your physician for his fees.

Billed Charges – The facility fee for your procedure billed out regardless of type of insurance coverage.

Contractual Amount- The agreed upon amount between our facility and your insurance that we have agree to accept for your procedure. The difference as per our contract with your insurance is adjusted off.

Co-pay- The amount established by your insurance as being your financial responsibility. Co-pays may vary by type of facility or type of service. Co-pays may also be required on top of your deductible and co-insurance.

Co-insurance- The percentage established by your insurance as being your financial responsibility. For example if your insurance covers 80% then your co-insurance is 20%. This amount may vary by type of facility or type of service.

Deductible- The amount established by your insurance company that needs to be paid out of packet by the patient before your insurance company will begin to pay your claims.

POS – (Point of Service)- Type of insurance that lets you access either a HMO level of benefits or a PPO level of benefits. Different co-pays and deductibles may apply depending on the type of coverage you choose to utilize.

EOB- Explanation of Benefits-The form your insurance company will send you showing you how your claim was processed and what was paid to the facility and what portion is patient responsibility.

Contracted Insurance- An insurance where we have negotiated an agreed upon amount of reimbursement for procedures performed at our facility. When contracted any amount billed over the contractual amount is adjusted off. Contracts vary among facilities so your financial responsibility may be different depending on that facilities contract for the same procedure. Being a contracted facility does not mean that all procedures will be covered by your insurance.

Non-Contracted Insurance- Insurance where there is no negotiated or agreed upon amount for procedures performed at our facility. Any provider adjustments quoted by your insurance company do not need to be accepted by our facility and we can request payment up to the billed amount.

DME- Durable Medical Equipment – Things like ice wraps, slings, crutches, post op shoes that your physician may order for you to assist in your recovery. Most of these things are not covered by your insurance and are considered patient responsibility.
Appeal- Process done by our billing department when your insurance does not pay your claim correctly based on our contract with them. Paperwork is submitted indicating how claim should have been paid and requesting your insurance to reprocess your claim. This can take anywhere from several months to sometimes 1-2 years.

Care Credit- Medical credit card that you can apply for and has various non-interest and interest baring pay back options. Can be used anywhere Care Credit is accepted for medical or dental procedures.