Health Insurance FAQs Insurance Participation Q: Why doesn’t the Kaplan Center accept my insurance? A: Dr. Gary and our other physicians feel very strongly that insurance companies should not be directing patient care by setting restrictions on medical testing and treatment. Operating outside the insurance system also allows our physicians to take the time necessary to ask you how you’re doing, listen to your concerns and discuss treatment options. Operating outside the insurance system also allows our physicians to provide you with an individualized treatment plan that may include “alternative and complementary medicine” techniques that may not yet be accepted by insurance companies. Bottom line, the medical treatment you receive should be the best care possible, and it should be determined by your doctor and you; not your insurance company. Q: Does the Kaplan Center participate with Medicare? A: 1) Dr Kaplan and Dr Lilienfield have opted out of Medicare. They can treat Medicare patients only under private contract. This means that neither the doctor nor the patient can file a claim with Medicare for the doctors’ services. The patient pays in full at the time of service. Patients who are covered under a secondary insurance policy (not Medigap coverage) may be eligible for reimbursement. If you have questions about your specific situation, please contact our billing department, and we will try to help you. 2) The Kaplan Center’s other medical providers, including our Physical Therapists, Psychotherapist, Chiropractor, and Dietitian do participate with Medicare. 3) Dr. Jeff Ericksen participates with Medicare, but is not currently accepting new Medicare patients. Q: Does The Kaplan Center participate with Tricare? A: No, we do not. Patients covered by Tricare must sign a balance-‐billing waiver each time they are seen. The waiver states that the patient understands we do not participate with Tricare, and he or she agrees to pay our full fee for services. We will, however, file your Tricare claims for you at no charge, so that we can indicate on the reimbursement form that you signed the waiver. Some Tricare plans pay for Kaplan Center services. If you have questions about your coverage, please contact your Tricare Service Center. Q: Does Kaplan Center accept workers compensation claims? A: No. Q: Does Kaplan Center accept Medicaid? A: No. Q: What should I ask my insurance company when I inquire about my out-‐of-‐network benefits? A: Ask your insurance company to provide you with the answers to these 4 questions: 1. “What is my out-‐of-‐network deductible?” 2. “Is my out-‐of-‐network deductible separate from my in-‐network deductible?” 3. “What is my coinsurance?” 4. “What is the maximum amount of out-‐of-‐pocket expenses I will be required to pay annually?”
Fee Slips and Services Q: On one fee slip, the doctor’s office-‐visit charge is $140, but on the next one, it is $180. Why is there a cost difference when it was the same kind of visit? A: Our physicians bill for office-‐visits based on the amount of time they spend with the patient. Before the doctor enters a treatment room, he or she sets a timer. When they exit the room, they stop the timer and note the number of minutes that they spent with the patient. The fee for the services rendered by the physician is apportioned among the services that the physician provided. Please note that it is rare for a 30-‐minute appointment to take exactly 30 minutes.
It is usually 1-‐5 minutes over or under. Occasionally, the visit will be significantly longer than the time scheduled when the doctor feels that more time is necessary. The provider does not waive his or her fee for this additional time. There are exceptions to the fee-‐for-‐time guideline: Several medical procedures have pre-‐set fees, which are explained to patients prior to scheduling their procedure. An example would be an appointment for PRP (platelet-‐rich plasma) therapy. Q: My doctor has recommended PRP (platelet-‐rich plasma) therapy to treat the arthritis in my knee. Will my insurance cover this procedure? A: Most insurance carriers have their reimbursement policies posted on their websites. At the time of this writing, Aetna and Carefirst both have policies of non-‐coverage for PRP because it is still considered by the medical establishment to be experimental/investigational. We encourage you to contact your carrier and find out for sure if they cover the procedure. The CPT code for PRP is 0232T. It is also possible that the injection itself may be covered. For example, the CPT code for an injection into a tendon or ligament is 0232T, and the CPT code for arthrocentesis (an injection into a joint space) of the knee is 20610.
Insurance Denials Q: Why is my office visit charge being denied as “integral to” (or bundled with) the more complex, primary procedure? A: If the “-‐25 modifier” is attached to the “office visit” (circled, if you are filing yourself), the insurance company’s decision to deny is an adjudication error; in other words, your insurance carrier did not process this claim correctly. Q: How do I appeal when the office visit is bundled with another procedure? A: You can usually handle this request for redetermination with a phone call to your insurance provider. Here is an example of what you could say: “My office visit was billed with the “25-‐modifier” to indicate that the office visit was a distinct and separately identifiable service from the medical procedures my doctor performed on the same date (probably Acupuncture and/or Osteopathic Manipulation). My claim was inappropriately denied (or bundled) because the “25-‐modifier” was incorrectly disregarded. Please send this claim back for reprocessing.” Q: I paid the Kaplan Center to file my insurance claims for me and my claim was denied. Does my filing fee include appealing my claim? A: The claim-‐filing fee covers the cost of having the Kaplan Center to file a “clean” claim with your insurance carrier, meaning we ensure that the claim is correctly coded. We also submit the form in the format preferred by your insurer, so that it will be processed more accurately and quickly. Claims denied for contract limitations are not the responsibility of the Kaplan Center and may not stand up to an appeal by the patient/subscriber. Claims denied in error due to poor insurance company adjudication practices also are not the responsibility of the Kaplan Center. These claims must be appealed either by a telephone request for redetermination or by written appeal. Please be sure to file your appeal within the timeframe prescribed by your insurance carrier; otherwise, you may lose your right to appeal. When appealing by phone always document: The date you called, The name of the person with whom you spoke, What was said, and Ask for a reference number for the call. If you receive your insurance through your employer and you find your claims are being routinely/repeatedly denied, you should report the problem to your company’s Human Resources Department, so they can intervene on your behalf. Otherwise, you should consider finding a new insurance carrier. Q: I usually file my own claims, but sometimes I ask the Kaplan Clinic to file my claims for me. When I do, my claims seem to get paid faster, while those I file are processed more slowly and sometimes get denied. Why?
A: When you file a claim by mail, the processor must manually enter into the insurance company’s computer system the following information: the treating facility; the facility address; the name of the care provider; ID numbers for the patient, facility and provider; service codes, and the corresponding diagnosis codes. In sum, there is a lot of information that must be entered, which opens the door for errors. For example, we have noticed that insurance company claim processors frequently code the diagnoses checked off on your fee slip from left to right, instead of properly connecting each diagnosis code with its corresponding treatment code. Without logical procedure code/diagnosis pairings, your claim will be automatically rejected. On the other hand, when the Kaplan Clinic files your claim, we do so in your insurance carrier’s preferred format, either electronically or on the “CMS 1500 Form.” Treatment and diagnostic codes are correctly matched and ranked. These claim forms are almost always electronically “read” and automatically processed. The result is that most of the claims we process are decided and paid quickly. Q: I feel like my insurance company is running me ragged with denials and requests for information. I feel overwhelmed! Is there anyone who can help me? A: You can make an appointment with June Guzdowski, the Kaplan Center’s Billing Director, to review your “Explanation of Benefits” (sometimes called a “Remittance Advice”) that your insurance carrier sends to you in response to each claim for reimbursement you submit. June will explain your insurance company’s adjudication, advise you if your claims are being improperly denied and tell you what you can do to appeal the decision. We also can assist you in your appeal for a fee. If you decide this is your best option, we will be happy to give an estimate of the cost of this assistance. There are also patient advocates whom you can hire to help you with your insurance problems. An advocate can be particularly helpful if your situation is very complicated. June can provide you with referrals for these services. FSAs and Nutritional Supplements (including herbal and homeopathic remedies) Q: Does my medical insurance cover the cost of supplements? A: No. The non-‐prescription nutritional supplements and medications that are available for purchase at the Kaplan Clinic are not covered under your insurance company’s prescription plan. Q: Can I get reimbursed for the cost of supplements through my employer-‐sponsored Flexible Spending Account (FSA)? A: Yes -‐-‐ if you have a doctor’s prescription for a supplement, it becomes a reimbursable expense under your Flexible Spending Account (FSA). When you file your claim for FSA reimbursement, remember to submit a copy of your prescription. Q: I used to be able to use my Flexible Spending card to purchase supplements and over-‐the-‐counter cold-‐care products, but now I can’t. Why? A: As of January 1, 2011, patients may not use FSAs to pay for over-‐the-‐counter drugs and medicines unless the patient has a doctor's prescription for the item. The new rule does not apply to items for medical care that are not medicines or drugs. Medical equipment, however, such as crutches, supplies such as bandages, and diagnostic devices such as blood-‐ sugar-‐test kits, still qualify for reimbursement by a health FSA, Health Reimbursement Arrangement (HRA), if purchased after Dec. 31, 2010, regardless of whether the items are purchased using a prescription. Q: How can I get the supplements I purchase at the Kaplan Center to be covered by my FSA Health Reimbursement Account (HRA), Health Savings Account (HSA) or Archer Medical Savings Account (Archer MSA)? A: If you want to submit the cost of your supplements to your FSA, HRA, HSA or Archer MSA, you should ask your physician for a prescription for the products he or she is recommending. Please mention your need for a prescription to your physician during your appointment, prior to purchase. Please submit a copy of your prescription with your reimbursement request.
The IRS rule governing FSAs apply to all tax-‐advantaged health care accounts, including Health Savings Accounts (HSAs), Health Reimbursement Arrangements (HRAs) and Archer Medical Savings Accounts (Archer MSAs).