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Understanding Your Insurance Coverage

Your insurance policy is an agreement between you and your insurance company. The policy lists a package of medical benefits such as tests, drugs and treatment services. The insurance company agrees to cover the cost of certain benefits listed in your policy. These are called “covered services".

Your policy also lists the kinds of services that are not covered by your insurance company. You have to pay for any uncovered medical care that you receive. Keep in mind that a medical necessity is not the same as a medical benefit. A medical necessity is something that your doctor has decided is necessary. A medical benefit is something that your insurance plan has agreed to cover. In some cases, your doctor might decide that you need medical care that is not covered by your insurance policy. Insurance companies determine what tests, drugs and services they will cover. These choices are based on their understanding of the kinds of medical care that most patients need. Your insurance company’s choices may mean that the test, drug or service you need isn’t covered by your policy.

By understanding your insurance coverage, you can help your doctor recommend medical care that is covered in your plan. Your doctor will try to be familiar with your insurance coverage so he or she can provide you with covered care. However, there are so many different insurance plans that it’s not possible for your doctor to know the specific details of each plan.

  • Take the time to read your insurance policy. It’s better to know what your insurance company will pay for before you receive a service, get tested or fill a prescription. Some kinds of care may have to be approved by your insurance company before your doctor can provide them.
  • If you still have questions about your coverage, call your insurance company and ask a representative to explain it.
  • Remember that your insurance company, not your doctor, makes decisions about what will be paid for and what will not.
  • Remember that your physician, not your insurance company, makes medical decisions and recommendations about what will benefit your health status.

Most of the things your doctor recommends will be covered by your plan, but some may not. When you have a test or treatment that isn’t covered, or you get a prescription filled for a drug that isn’t covered, your insurance company won’t pay the bill. This is often called “denying the claim.” You can still obtain the treatment your doctor recommended, but you will have to pay for it yourself. If your insurance company denies your claim, you have the right to appeal (challenge) the decision. Before you decide to appeal, know your insurance company’s appeal process. This should be discussed in your plan handbook. Also, ask your doctor for his or her opinion.

If your doctor thinks it’s right to make an appeal, he or she may be able to help you through the process.

Source: American Academy of Family Physicians, 2001

Financial Responsibilities

We are committed to providing you with high quality medical services regardless of our participation status in your insurance plan. We will help you receive your maximum allowable insurance benefits. Our surgeons currently only participate in Medicare. Please be aware that due to current federal regulations, we are obligated to collect all applicable co-payments, co-insurance, and bill for all services. To assist you in understanding your financial responsibilities, please refer to the following:

Identification: Due to the stringent regulations governing the healthcare industry and the complex nature of our surgical practice, the office requires the Patient Registration Form be completed in full and copies of the front and back of each patient’s insurance card(s) be obtained (including secondary insurance information). This includes proper identification numbers, subscriber data and complete insurance claim address. Patients who are unable to provide this complete information will be fully responsible for all charges. Should complete information be provided subsequent to examination or treatment, we will process claims on behalf of the patient to facilitate reimbursement.

Payments Accepted: For your convenience payments may be made in the form of Master Card, Visa, check or cash.

BCBS: Effective January 1, 2003 we are no longer a participating provider with the Blue Cross/Blue Shield carriers. We have developed an insurance reminder resource for BCBS and all other non Medicare patients, available electronically here. 

Medicare Patients: As a participating provider with the Medicare program, we will submit your insurance claim. Medicare automatically files to your secondary carrier when complete and accurate insurance information has been provided. However, secondary payments not received within 30 days from date of filing, will become the financial responsibility of the patient. Patients wishing to submit their own secondary claims may contact the billing office. We will be happy to provide you with the necessary paperwork. We urge all Medicare patients to review Medicare and You 2009- an annual publication of the Centers for Medicare and Medicaid which includes current costs, coverage, preventative services, health and prescription drug plans, and rights and appeals information.

Office and Non Medicare Patients: We will submit your insurance claims directly, provided the information we have obtained from you is accurate and complete. For office visits and office procedures, we request payment in full at the time of service. Again, we will file claims on your behalf so that your carrier may apply amounts to your deductible or reimburse you directly. Occasionally, carriers will inadvertently forward your payment to our office. In these instances, we will automatically refund the money to you. When payment arrangements must be made, we encourage you to contact our billing office. We have developed an insurance reminder resource for all non Medicare patients, available electronically here. 

Hospital and Surgical Charges: We are happy to submit your claim (s) directly to your insurance carrier for all hospital and surgical services. However, it is the policy of the Practice to bill patients directly for all charges not paid within 30 days of the service. We will provide financial disclosure forms for elective surgery, which will request a deposit prior to surgery. We are happy to assist you in any preauthorization and appeals process with your insurance.

Billing Inquiries: Direct line is (202) 895-1446

For assistance regarding insurance and/or payment issues contact our Billing Office. Our billing office accepts telephone inquiries between 8:30 a.m.– 12:00 p.m. and 1:00 p.m. – 4:30 p.m.. Billing staff will make every attempt to assist you at the time of your call. To facilitate their efforts, please have the necessary information available that you need to discuss.

Please note: Hospital and other ancillary services – i.e. lab, medical imaging, etc. are not part of our practice. Please call the number(s) listed on those statements for assistance.

Finance/Insurance Resources

At Foxhall Surgical Associates, P.C. we place a high priority on patient education. Understanding insurance policy coverage and terminology can be daunting, but a well educated consumer can make informed choices when selecting their health insurance plan. To assist our patients in educating themselves on insurance plans and coverage, we have compiled a list of resources either developed by or utilized by our practice. Please take a moment to review.