Our patient accounts staff answers to frequently asked billing questions at Summit Medical Group. Topics include bringing your insurance card to all medical visits, the ABC's of co-pays, deductibles and co-insurance, and the difference between in-network and out-of-network services.

1. Billing and Insurance
Presented by: Revenue Cycle Department
August 7th 2013

2. Objectives
Present an overview of insurance and the billing
process
Answer some of the questions most frequently asked by
our patients
Let you know about the resources Summit Medical
Group has available to assist you with your billing
concerns

3. Accurate Billing Starts with your
Insurance Card
• Wrong insurance information delays processing of
claims and leads to billing errors which can be
reflected in your statement.
• Bring all your current insurance cards to every visit.
• Notify us when you have a change in
insurance, address, or phone number.

4. http://summitmedicalgroup.magnify.net/video/News-and-Happenings-
Insurance-C;recent
Insurance Cards Video

5. Participating Insurance Plans
• Aetna
• Aetna Medicare
• Amerihealth
• Anthem BCBS
• CHN
• Cigna
• Coventry (First Health)
• Empire BCBS
• Great West
• Horizon
• Horizon Medicare
• Magnacare
• Medicare (Traditional)
• Railroad Medicare
• Oxford Freedom
• PHCS/Multiplan
• Qualcare
• United Healthcare

6. Medicare
• Traditional Plans
• Medicare Advantage Plans
 Aetna Medicare
 Horizon Medicare Blue

7. Non-Participating Plans
• Oxford Liberty
• GHI/Emblem Health
• All Other Medicare Advantage Plans

8. ….but there are always exceptions!
• Oxford Liberty participating at some locations.
• GHI/Emblem Health participating when the
Qualcare logo is on the front of the card.
• United and Oxford Medicare Advantage plans
participating at some locations.

9. Look for insurance information on the
Summit Medical Group website
http://www.summitmedicalgroup.com/
Summit Medical Group website

10. Intention of the Visit
Summit Medical Group providers do not code
your visit according to your benefits.
The provider codes according to what was done
during the visit.
In addition to the physical or office visit you may
be billed for lab work, x-rays, and other
diagnostic testing

11. How a Service is Coded
You scheduled a routine colonoscopy
• Screening – no family history, no symptoms
• When billed as a screening there is no cost
sharing to the patient
• During the procedure a polyp is detected and
removed.
• The diagnosis changes from routine to diagnostic
• Cost sharing now applies

12. Know Your Benefits
Always check with your insurance carrier to
confirm your benefit coverage

13. A Few Questions to Ask
• Is my provider participating in this plan?
• Am I required to select a PCP, Primary Care
Provider?
• Does my plan require referrals?
• Is this a covered benefit under my plan?
• What will my cost sharing be?

14. What is Cost Sharing?
Cost sharing is the patient balance that remains
after the insurance plan has applied payment
for covered services according to your benefit
plan.
It is the amount you are expected to pay.

15. What does it include?
Cost Sharing includes:
• Copay
• Deductible
• Coinsurance

16. COPAY
• A fixed amount you pay
for a covered health
care service , to be paid
when you receive the
service
• The amount can vary by
the type of covered
health care service.
• $15 primary care
• $25 specialist
Primary Care Visit
Allowed Amount $100.00
Insurance Pays $ 85.00
Patient Copay $ 15.00
Specialist Visit
Allowed Amount $100.00
Insurance Pays $ 75.00
Patient Copay $ 25.00

17. Deductible
• The amount the patient
owes for healthcare
services before your
health insurance plan
begins to pay
• Deductible may not
apply to all services
• Deductibles are applied
annually
Plan Deductible
$1000.00
Your plan won’t pay
anything until you’ve
met your $1000.00
deductible for health
care services subject to
the deductible

18. Coinsurance
Your share of the costs of
a covered health care
service, calculated as a
percent of the allowed
amount for the service
Co-insurance plus
deductible may apply in
some cases
Allowed Amount $100.00
20% Co-insurance $ 20.00
Insurance Pays $ 80.00
Allowed Amount $100.00
Deductible $ 20.00
20% Co-insurance $ 16.00
Insurance Pays $ 64.00

19. Cost Sharing Tools
Most commercial Health Insurance carriers have cost
estimators on their websites to help you estimate
your out-of-pocket expense.
• Calculate your estimated costs for procedures, office
visits, lab tests, and surgeries.
• Compare what your cost sharing will be at different
providers and locations.

20. Medicare Cost Comparison
Medicare also provides transparency into healthcare
costs on their website
• You can compare hospital pricing for hospital
inpatient and outpatient care
• The annual Medicare and You booklet also provides
insight into Medicare covered benefits
Visit the Medicare website: www.medicare.gov

21. Your Billing Statement
• Statements go out every 35 days
• You will receive a statement when your balance is
$10 or greater.
• Summit Medical Group bills patients according to the
Explanation of Benefits (EOB) that we receive from
your insurance carrier.
• Match your EOB to the Summit Medical Group
statement to verify that you have been accurately
billed.

22. Explanation of Benefits
http://summitmedicalgroup.magnify.net/video/News-and-
Happenings-Understandi;recent
Understanding EOB video

23. How to Read your Statement

24. How are my Payments Applied
The copays you pay at the time of service are applied to
that date of service.
In some cases your copay may be applied to an
outstanding balance for a different date of service.
This is done to prevent older balances from aging and
going to collections.

25. Convenient Ways to Make a Payment
• Mail a check to the payment address on your
statement. Sorry no credit cards by mail.
• Call Patient Accounts at 908-790-6500
• Make a payment at your next visit to any
SMG location
• Make a payment on-line at
http://www.summitmedicalgroup.com/
Summit Medical Group website

26. Pre-Collection Process
• You will receive 3 statements before
balances are flagged at collect status
• Statement messages indicate the aging of
your statement balance

27. Statement Messages
Second Statement:
• Your account is overdue; please pay this
balance immediately.
Third Statement:
• Your account is in collections status; please
contact the office immediately.

28. Collection Letters
You will receive a separate letter from Summit
Medical Group when your balance is billed on
a second and third statement.
The letter is to remind you that your account is
in collect status and if the balance is not paid
it will go to our outside collection agency.

29. Collection Policy
• Summit Medical Group does send aged balances to
a collection agency.
• Summit Medical Group has contracted with Simons
Collection Agency to help us recover unpaid patient
balances.
• Account balances are sent to the collection agency
after you receive 3 statements and you do not make
a payment.

30. What to Expect from the Collection
Agency
• Patient receives automated and live calls from the
agency.
• Collection balance is not reported to the credit bureau
until 90 days after placement with the agency.
• Payments can be made directly to Simons or to
Summit Medical Group.
• Simons will update Summit Medical Group records to
show your payment was made and clear your
balance.

31. We are here to help
• Assist you in Understanding your statements
• Offer payment plan options
• Provide Financial Counseling
• Summit Medical Group is a billing resource
for our patients; however, your Insurance
Plan is and should be the first resource for
questions about your benefits.

32. Patient Accounts Department
• Patient account specialists are available to answer
your questions and take your payments over the
phone Monday – Friday
• 9:30 a.m. to 4:30 p.m
• Phone number: 908-790-6500
• Billing e-mail: billings@smgnj.com

33. Financial Counselors
• Located at 1 Diamond Hill Road, Berkeley Heights in
the Lawrence Pavilion.
• 150 Floral Avenue, New Providence
• Appointments can be made for on-site visits.
• Walk-ins are also welcome.
• Annette Austion-Brown 908-790-6596
• Courtney Parker 908-273-8896
• William Stratton 908-273-8957

34. Thank you
Questions

35. Participating Plans
• Although we participate with these plans benefits
vary depending the group package – Use Oxford
Liberty as an example
• Some services may be considered non-covered
services based on your individual plan
• Check with your insurance carrier for confirmation of
benefits and cost sharing
• Information received is not a guarantee of payment

36. HMO
• Most HMO plans require you to select a
Primary Care Provider – PCP
• Primary Care Provider is a doctor whose
specialty is Internal Medicine, Family
Medicine, or Pediatrics
• Patients can select their PCP or change their
PCP by calling the health plan.
• Some HMO plans do not have out-of-network
benefits.

37. Referrals
• Some plans may require a referral from your
PCP to a specialist or facility
• Summit Medical Group will get the referral for
our patients who have selected an SMG
provider as their PCP
• Patients who have selected a PCP outside
SMG must get a referral from their PCP

38. Authorizations
• Some services such as Imaging or
Surgery may require prior-authorization
under the terms of your health
insurance plan
• Summit Medical Group will obtain the
authorization for procedures ordered by
our providers as required by your plan

39. Medicare
There are two main ways to get your
Medicare coverage
• Traditional Medicare
• Commercial Medicare Advantage plans

40. Decide how to get your Medicare
Coverage
Traditional Medicare includes:
• Hospital Insurance (Part A)
• Medical Insurance (Part B)
You will need a separate plan for your Part D,
Prescription Drug Coverage
Medicare Advantage Plan:
• Combines Part A, Part B and usually Part D

41. Understanding Benefits Cont’d
• In addition to the physical or office visit you
may be billed for , lab work, x-rays and other
diagnostic testing, procedures
• Your insurance carrier may apply co-
insurance and deductible to some of these
procedures in addition to your co-pay for the
visit
• Authorizations; Waivers and ABNs