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>>Download a Patient's Comprehensive Guide to Insurance Basics and Frequently Asked Questions Document
Most of the orthotic and prosthetic services provided by Hanger Clinic are covered by health insurance, including Medicare Part B. The amount of coverage available for services can vary quite a bit depending on the type of policy you hold. If you have more than one insurance plan, it is possible that the entire cost of your care could be covered. In most cases, some percentage of "co-pay" is required to be paid out-of-pocket by the patient at the time the orthosis or prosthesis is delivered. Before your first appointment, it is a good idea to visit with your insurance company, or prospective insurance company, to understand exactly what benefits are available for O&P services. Working closely with your healthcare team is also beneficial and can help to maximize your benefits.
Together we can assess your needs and abilities, which will assist in determining the most appropriate orthotic and prosthetic device for your lifestyle. This may also give additional leverage when working and/or negotiating with your insurance company.
Hanger Clinic has tremendous experience working with the Medicare program. Our comprehensive understanding of reimbursement, regulations and procedures help us to answer your questions regarding eligibility, bills, deductibles, and Medicare notices. Medicare will pay 80% of its "fee schedule" for covered orthotic and prosthetic services, after your annual deductible has been met. Generally there are no caps on types of technology covered by Medicare, as long the orthotic or prosthetic device is medically appropriate, is prescribed by a treating physician, and otherwise meets Medicare's coverage criteria. Again, it is very important to work closely with your healthcare team to determine which prosthetic or orthotic product is the most appropriate for your lifestyle. To learn more about Medicare you can call 1-800-MEDICARE, or visit their website at www.medicare.gov or www.medicareadvocacy.org.
A contract between an insurance provider (i.e. an insurance company or a government) and an individual or their sponsor (i.e. an employer). The type and amount of health care costs that will be covered by health insurance provider are specified in writing in a member contract.
The amount the policy-holder or their sponsor (i.e. an employer) pays to the
health plan to purchase health coverage.
The amount that the insured must pay out-of-pocket before the health insurer pays its share. For example, policy-holders might have to pay a $500 deductible per year, before any of their health care is covered by the health insurer. It may take several doctor's visits or prescription refills before the insured person reaches the deductible and the insurance company starts to pay for care. Some plans may have separate deductibles for specific services.
The amount that the insured person must pay out-of-pocket before the health insurer pays for a particular visit or service. For example, an insured person might pay a $45 co-payment for a doctor's visit, or to obtain a prescription.
Instead of, or in addition to, paying a fixed amount up front (a co-payment), the co-insurance is a percentage of the total cost that insured person may also pay. For example, the member might have to pay 20% of the cost of a service over and above a co-payment, while the insurance company pays the other 80%.
Not all services are covered. The insured are generally expected to pay the full cost of non-covered services out of their own pockets.
Some health insurance policies only pay for health care up to a certain dollar amount. The insured person may be expected to pay any charges in excess of the health plan's maximum payment for a specific service. In addition, some insurance company schemes have annual or lifetime coverage maximums. In these cases, the health plan will stop payment when they reach the benefit maximum and the policy-holder must pay all remaining costs.
Similar to coverage limits, except that in this case, the insured
person's payment obligation ends when they reach the out-of-pocket maximum,
and health insurance pays all further covered costs. Out-of-pocket maximums can
be limited to a specific benefit category (such as prescription drugs) or can
apply to all coverage provided during a specific benefit year.
A health care provider on a list of providers preselected by the insurer. The insurer will offer discounted coinsurance or co-payments, or additional benefits, to a plan member to see an in-network provider. Generally, providers in network are providers who have a contract with the insurer to accept rates further discounted from the "usual and customary" charges the insurer pays to out-of-network providers.
A certification or authorization that an insurer provides prior to medical service occurring and typically contingent upon eligibility, medical necessity, and benefits however not a guarantee of payment.
A document that may be sent by an insurer to a patient explaining what was covered for a medical service.
A recommendation to consult the (professional) person or group to whom one has been referred; "the insurance company says that you need a written referral from your physician before seeing a specialist".
Coverage varies with each insurance company. We encourage you to check with your insurance company or your employer about this. Please refer to your insurance member handbook or call your insurance company with questions. Remember! Insurance coverage varies greatly from plan to plan. It is important to familiarize yourself with the terms of your insurance coverage.
There are many different types of health insurances. The most common plan types include Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). It is very important to understand your benefits coverage before seeking care by reviewing your contract or contacting your insurance. Your health benefits will vary depending on what type of plan you have. Some key items to understand include: Does your insurance require you to select doctors and providers from a list? (This is often called a provider network.) If you use a provider outside of the allowed network, will your insurer pay for any portion of the care? (This is often called an "out of network" benefit.) Specifically, what services are not covered by your insurance? (For example, cosmetic surgery is generally not covered. Dental services are not typically part of medical coverage and require separate dental insurance.)
Common Reasons Services are denied: Your plan says the health care service or item you want covered is not medically necessary. You did not get a prior authorization before you received the health care service or item, and your plan says you needed one. Your plan says the health care service or item is not covered by your plan.
It is first very important to understand what type of plan you have to determine if Hanger is an in-network or out-of-network provider.
In-Network Provider: A health care provider on a list of providers preselected by the insurer. The insurer will offer discounted coinsurance or co-payments, or additional benefits, to a plan member to see an in-network provider.
Out-of-Network Provider is one which has not contracted with your insurance company for reimbursement at a negotiated rate. Some health plans, like HMOs, do not reimburse out-of-network providers at all, which means that as the patient, you would be responsible for the full amount charged. Other health plans offer coverage for out-of-network providers, but your patient responsibility would be higher than it would be if you were seeing an in-network provider. Although it may initially cost you more money, there may be times when you might find it necessary, or even advisable, to use an out-of-network provider.
Benefits (the amount payable by the insurance company to a claimant or assignee) will be directly related to the type of plan you have (see above) and the service/item you are seeking (covered or non-covered under your plan).
This will depend on your plan, it is very important to review your coverage or contact your insurer.
Coverage limits: Some health insurance policies only pay for health care up to a certain dollar amount. The insured person may be expected to pay any charges in excess of the health plan's maximum payment for a specific service. In addition, some insurance company schemes have annual or lifetime coverage maximums. In these cases, the health plan will stop payment when they reach the benefit maximum and the policy-holder must pay all remaining costs.
Out-of-pocket maximums: Similar to coverage limits, except that in this case, the insured person's payment obligation ends when they reach the out-of-pocket maximum, and health insurance pays all further covered costs. Out-of-pocket maximums can be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.
Initially refer to your plan and contact your insurer is your most effective means of understanding your coverage. (Additionally Hanger Clinic’s Financial Counselors are available to guide you through this). In some cases, Financial Counselors may enlist your support during the coverage process with your insurer, however ultimately you are responsible to educate yourself to your insurance plan and its coverage/requirements.
Often insurance companies quote very basic benefit information to their members. However, once you are evaluated by a clinician at Hanger Clinic, additional details are available that allows our administrative staff to conduct a more in-depth verification of benefits. There may be certain exclusions within your policy that may not be evident without very detailed information as to the exact type of device that has been proposed. In addition, our administrators are trained to research you insurance company’s medical policy bulletins, which explain the criteria your insurance company uses to determine medical necessity.
In a non-covered scenario Hanger Clinic will typically contact your insurance plan to obtain your eligibility and Out-of-Network benefit information, submit your insurance claim if your plan agrees to pay us directly.
As well as a courtesy, upon request, Hanger Clinic may bill your insurance company on your behalf following your full payment to Hanger Clinic for any non-covered item/service. However, we ask that you participate in helping us by providing insurance card copies and other critical documentation deemed necessary in order to smoothly expedite filing.
If there is a discrepancy we will be happy to review your account and if deemed applicable make any necessary refunds.
Yes, in many cases there are external funding resources available for your consideration that may allow you to budget more comfortably. Hanger Clinic’s Financial Counselors will offer you guidance in this area.
In many instances it is our pleasure to assist in appealing a claim, however please be advised filing an appeal will not guarantee that the insurance company will pay more on your bill, but the claim will be reviewed for reconsideration. Many insurance companies, including Medicare, require that you sign an Appointment of Representative form which gives your written consent to have another person write an appeal on your behalf.
Once your insurance carrier pays their portion of the bill, they will send you an explanation of benefits (EOB) to show how the claim was paid. How the carrier paid the claim is based on their contract with us and their contract with you. Additionally most plans have a co-insurance (Coinsurance indicates how an insurer and an insured will share the costs of a bill that exceeds the insurance policy's deductible).
Hanger Clinic’s Financial Counselors will be available and provide you a written cost estimate for your review/approval.
With a deductible plan, there's a running total of how much you spend on certain covered services until you reach your deductible. But not all payments apply to the deductible. Some services require only a copayment, which is not added to your running total.
Since our services are unique and primarily custom made to fit your needs, it is responsible to ask for payment as deemed appropriate (i.e. deposit/co-pays/deductibles). Upon completion of your clinical evaluation, our Financial Counselors will present your cost estimate to you for your approval and answer any questions you may have. By asking you to be prepared to make payment on the day of your appointment, we are able to control our cost of billing more efficiently as well as provide you with a variety of payment options.
Payment is accepted by: Cash, Check, Credit Card or 3rd Party Patient Financing
Please communicate your specific questions to Hanger Clinic’s on staff Financial Counselors, these team members are trained in traditional funding as well as public/private funding resources that may be available.
Hanger Clinic is happy to offer an extended term, dependent upon the total amount owed, up to 6 months (subject to application approval and total amount owed).
Since our services are unique and primarily custom made to fit your needs, we prefer not to quote. Following your complete clinical evaluation, our Financial Counselors will present your cost estimate to you for your approval and answer any questions you may have. Costs are provided as an estimate for your review/ discussion/ approval. Estimates are based on preliminary information for the insurance company and patient/responsible party agrees to make payment in full if the insurance company fails to pay.
It is our goal to please both the patient and ordering physician and will make every reasonable effort to do so timely.
Excerpt from Hanger Clinic’s Warranty: (please be prepared to review the warranty in its entirety to understand company and patient obligations): Hanger Clinic warrants each custom device made by Hanger Clinic to be free from defective workmanship and/ or parts, under normal service and use, for six (6) months from the delivery date. The company’s obligations under this warranty are limited to the no-charge repair or replacement of the part or part of the device that the company determines to be defective. This repair or replacement may be made at any Hanger Clinic location within the United States. Items not manufactured by Hanger Clinic are warranted for the length of the warranty supplied by the manufacturer of the part or device.
Ensure as a patient you understand that the date of service is the date you receive your service/item and acknowledge the receipt by signature. Your signature on an Advanced Beneficiary Notice might be required for services that may not be covered.
As a patient it is your responsibility to notify Hanger Clinic if you have received the same or similar device from another provider within the past six months.