Podiatrists @ Placentia-Linda Foot & Ankle Group

 

UNDERSTANDING MEDICAL INSURANCE COVERAGE

Podiatry as is all other medical specialities is covered by medical insurance. Medical insurance today is very complicated and most patients are at a disadvantage in trying to understand what is going on when a doctor bills for a medical service and the insurance company pays the bill.  This web page is designed to help explain what is going on in most cases.  Medical billing is performed in office by electronic transfer for the Placentia-Linda Foot and Ankle Group. The doctor's office is located in Placentia, CA in the Placentia-Linda Hospital Medical Office Building. The doctor's office serves the surrounding cities of Placentia, Yorba Linda, Fullerton, Anaheim Hills and Brea, CA. If you have any questions regarding your insurance coverage, please contact our office and we will research your coverage benefits.

 MEDICAL INSURANCE

In discussing insurance, this discussion will pertain to Preferred Provider Organizations (PPO), Point of Service (POS) and indemnity insurance plans that allow a patieint to select their own doctor. Before any office viist, the patient's insurance should be verified by the doctor's office to determine insurance benefits for the office visit, procedure benefits and coverage of optional items such as custom shoe inserts.  Besides your coverage, any outstanding deductible amounts must be determined.  The deductible remaining on your insurance is based on the amount the insurance company allied to your deductible, and this may not be the same amount as you paid to a previous medical office.  As such, it is important to insure that the office you are paying a deductible to actually is billing your insurance.

Once you have had treatment by the doctor's office, a standard form is used to electronically send the billing to the insurance company.  The fees charged are based on the medical industry standards that been developed over the years in which each service has a specific number assigned to the service that was billed to the insurance.  Typically, a month and a half passes before any payment is received by the doctor's office.  Patients have a lot more clout in getting insurance companies to pay their bills and a call to the insurance company can significantly speed up the claims process.  Most claims go very smooth and there are no delays.  Sometimes, the delay is not for any good reason other then to delay the claim and in other cases the delay is because the insurance company is contesting the billing.  Usually, a form is received by the doctor's office after about a month stating the problem with the medical claim, and the doctor than has to write a special report or document some other medical justification for the reason the medical care was rendered.  When payment is finally received, the form that accompanies the payment is called an EOB which stands for Explanation of Benefits.

Over the years, patients have wondered why the doctor charges one fee and the insurance company pays an entirely different amount.  In most cases, the doctor is a preferred provider for the insurance company and the fee for the medical service that is provided is set by the insurance company.  For the patient, when the Explanation of Benefits is examined, it appears that the doctor's office over charged the insurance company when in fact the amount paid to the doctor's office is the exact PPO rate.  Most doctors charge every insurance company the same fee for the service provided and let the insurance company determine what the PPO contracted rate is for that specific insurance company. Unfortunately, even through there is no discount because the amount going to be paid to the doctor never changes under the PPO contract, the Explanation of Benefits states that a savings occurred in reducing the doctor's original fee.

In processing medical claims, insurance companies have many different reasons for disputing the claim such as a pre-existing condition, the medical service was unnecessary, the doctor is not a PPO provider or medical records must be reviewed to justify payment of the claim.  When the disputed claim is received by the doctor's office and the doctor sends back the requested information, another month can pass before payment is received by the doctor's office.  As a patient, you can move the process along by calling the insurance company to inquired why the dispute has not been resolved.  In many cases there is no reason for the extended delay in payment other than the paperwork must move through a large bureaucracy prior to payment or the paperwork is sitting in a stack on someone's desk.  Between the doctor's office and the patient working together, claims can be paid in a timely manner.

When a procedure is not paid for by the insurance company, the doctor's office can bill the patient for only those services that are not covered by the insurance policy and this information will be listed on the Explanation of Benefits.  Most offices will inform the patient of the expectation that the medical service will be not covered by the insurance company prior to the service being rendered.  For Medicare patients, there is a pre-treatment form that lists which services Medicare does not cover and the cost of each f these services.

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Foot and Ankle Fractures   Diabetic Foot Problems   Callouses  Metatarsal Stress Fracture

Offering Podiatric Surgery, Foot Surgery, Wound Care, Sports Medicine and Foot Orthotics,
Foot and Ankle Surgery and other treatments for Foot and Ankle Pain and Injuries.
Podiatry and Foot related diagnostics and procedures are performed in Placentia / Yorba LInda, CA.

Podiatrists Dr. Mark Reed and Dr. Melanie Reed
Placentia Linda Foot Ankle Group Podiatry Associates
Office of Mark Reed, DPM: 1275 N. Rose Drive, Suite 136 | Placentia, CA 92870 | Tel: 714-528-FOOT
Office of Melanie Reed, DPM: 1275 Rose Drive | Suite 124 | Placentia | CA 92870 | Tel: 714-528-7777
Yorba Linda Satellite Office: 21580Yorba LInda Blvd | Yorba Linda, CA 92887

www.footpain.org

Serving Placentia, CA and the surrounding North Orange County cities of Yorba Linda (92886, 92887), Brea (92821, 92822, 92823), Anaheim (92807, 90808), & Fullerton 92831, 92832, 92833, 92834, 92835 92836), Tustin (92780, 92781, 92783), and Orange (92861 92862 92865 92866 92867 92868 92869)