What to Know About Using a Third-party Payer

You should be aware of the following if you are using a third-party payer to pay your charges:

You must add your newborn to your policy. No one else will or can do this for you. Delays in enrolling your newborn may result in out-of-pocket costs to you.

You are solely responsible for providing us with your policy information at the time of service, and for ensuring your policy information remains current.

Your policy is a contract between you and your third-party payer.

You are solely responsible for fully understanding what your policy will or will not cover. Our courses of treatment, prescriptions and referrals are guided by what is in the best interest of the patient’s care; we do not tailor our services to the whims of a third-party payer. You—as an informed consumer—are solely responsible for accepting or refusing services, prescriptions or referrals based the specifics of your policy’s coverage.

Why can’t you tell me what my policy covers?

Of the dozen or so third-party payers we are in-network with, there are literally hundreds of possible policies underwritten by these payers. Trying to track the specifics of all those policies for the several hundred patient encounters we have each month is simply not doable, and the fact is that level of detail about your specific policy is not readily available to us. Your policy is a contract between you and your third-party payer. As a participant in a legal contract, it is your responsibility to understand that contract. We have a “general” understanding of what payers are or are not paying for, are or are not applying to deductibles, but these are merely general observations based on past experience. What your specific policy will or will not cover is for you to understand.

As a courtesy to you, we will file a claim once with your payer using the policy information you provided. Incorrect or incomplete information may result in delays or claim denials that result in out-of-pocket costs to you. We are not obligated to re-file a claim due to your failure to provide correct policy information.

Any dispute with your payer over what should or should not be covered is a dispute between youand your payer. We will hold you financially responsible for all charges deemed “patient responsibility” by your payer, regardless of any dispute.

All information provided by your payer regarding the potential of your policy to cover a future claim for services rendered is pure speculation. Therefore, neither we nor you have any guarantee that your payer will pay a claim until the actual claim is filed and processed, regardless of anything the payer said beforehand.

But my payer said…

Call your payer to inquire about your coverage. As you navigate their labyrinth of a phone tree, you will hear—probably no less than six times—a legal disclaimer stating that any and all information given to you on this phone call is based on assumptions about your policy for the date of service in question, and that the only coverage determination that counts is the one made when the actual claim is processed. We are simply giving you fair warning that your payer may process a claim in contradiction to what we were both told prior to services being rendered. It is a risk in using a third-party payer that you have to assume.

Third-party payers reserve the right to alter or reverse a prior claim payment—at any point in the future—should they receive or uncover information that results in a different payment amount or in a claim denial. Therefore, we will bill you—at any point in the future—for any balance due that results from your payer altering or reversing a prior payment.

But my payer paid…

Infuriating, but unfortunately true. We have returned payments for dates of service over a year-and-a-half prior—and then had to go back to the patient’s family to request payment. We are simply giving you fair warning to never consider a claim paid. It is a risk in using a third-party payer that you have to assume.

If you are using a policy obtained via an Affordable Care Act (ACA) exchange, and you are in month 2 or 3 of the “Three-month Grace Period” for premium non-payment, we will not accept your policy as payment for services rendered. Your policy will not be accepted until your third-party payer confirms that your policy is again in good standing. If you wish to receive services in our clinic during this period, you may do so as a self-pay patient.

In month 2 or 3 of what?

If you acquired a subsidized policy on an exchange, i.e. you are receiving taxpayer dollars to “lower” your premium, the ACA requires your third-party payer to continue your policy for three months should you stop paying your premium. After those three months, your payer will retroactively terminate your policy back to day 1 of month 1 of your delinquency, i.e. you had no coverage for those three months. The ACA requires your third-party payer to take the loss for any services paid during month 1, but your payer is allowed to come back to us and request that all monies paid for services rendered in months 2 and 3 be returned. Thus, the cost of your non-payment is forced on to us—leaving us in the position of now having to chase after you for payment on services that werepaid, but are now not paid. You are not paying your premium, so what expectation should we have that you will pay us? None. Therefore, if you are in the “Three-month Grace Period,” your policy has no value, and will not be accepted as payment for services rendered in our clinic.

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