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Office Policies

Billing & Insurance

We accept most PPO’s, Medicare and ‘Brown and Toland Medical Group’ and ‘Hill Physician Medical Group’ HMO’s. You will be responsible for ALL co-pays, deductibles and non-covered services. We accept all major credit cards, and personal checks.

Our billing office will first submit a claim to your insurance carrier(s). When the claim is processed, your insurance will also send an Explanation of Benefits (EOB) to you. Please note that the name of the provider on the EOB will be “UCSF Clinical Integrated Partners“

For covered services, you will also be responsible for anything that is patient responsibility, including deductible, co-insurance, etc.  If you have questions about your benefits, please contact your insurance provider.

For any questions related to claims and billing please call (888) 362-5443.

Working With Your Insurance

Health insurance can seem quite confusing – and different plan options have different rules and regulations depending on which state you live. It is ultimately up to you, the patient, to understand the details of your plan’s terms, benefits and coverage options in order to avoid any unexpected costs and hassles.

Health Insurance Providers

San Francisco Otolaryngology physicians accept most major Preferred Provider Organization (PPO) plans and are preferred providers with the following HMO medical groups: Brown & Toland Medical Group, Hill Physicians Medical Group, and Meritage Medical Group. This increases your access to care even if you switch insurance carriers.

We are listed as participating providers for the following:

Unfortunately, we’re not a participating provider with Medi-Cal or its related managed care plans.

A Note on Testing:

We will seek prior authorization for any test(s) ordered by your physician. Due to changes in insurance carrier policies, many patients have plans with a high deductible. Please note prior authorization does not guarantee payment from your insurance provider. You may still be responsible for additional payment depending on your insurance benefits.

Please contact your insurance company to determine your deductible and any potential charges you may incur.

Glossary

Below is a list of basic terms you may come across while learning more about health insurance:

Co-pay/Co-payments
A cost-sharing arrangement between an insured person and health insurance company wherein the insured person pays a fixed dollar amount for covered medical services. For example, a PPO may require a $20 “co-payment” for normal services delivered during a physician office visit; after which the insurance company often pays the remainder.

Coinsurance
A cost-sharing arrangement between an insured person and health insurance company wherein the insured person pays a stated percentage of expenses for covered medical services after the deductible amount, if any, was paid.

Deductible
A cost-sharing arrangement between an insured person and health insurance company wherein the insured person is required to pay a fixed dollar amount each benefit period (typically a year) before the health insurance company will reimburse for covered health care expenses. Plans may have both per individual and family deductibles.

Exclusion Period
A period of time during which an insurance company can delay their coverage for a pre-existing condition. Sometimes this is called a pre-existing condition waiting period.

Explanation of Benefits (EOB)
Statement sent by insurance companies to persons who have experienced a claim under the health plan. An EOB details the charges for the services received, the amount the health insurance company will pay for those services, and the amount the insured person will be responsible for paying.

First Dollar Coverage
A term for not having to meet a yearly deductible amount prior to receiving reimbursement or payment for a medical service.

Health Maintenance Organization (HMO) 
A prepaid health plan which covers certain aspects to patient treatment; for instance: doctors’ visits, emergency care, surgery, lab tests and therapy. In a HMO, one must choose a primary care physician who then coordinates all care and makes referrals to any specialists that may be required. Also in a HMO, one must use the doctors, hospitals and clinics participating in a specified network (usually within a specified geographic area).

Indemnity Health Plan 
These plans are also sometimes called “fee-for-service”; and existed primarily before the rise of HMOs and PPOs. With indemnity plans, the individual has their choice of providers without effect on reimbursement. The fees for healthcare services are defined by the health care providers and vary from physician to physician, hospital to hospital.

Lifetime Maximum
A cap on the benefits paid for the duration of a health insurance policy.  Many policies have a lifetime limit of $5 million, which means that the insurer agrees to cover up to $5 million in covered services over the life of the policy.  Once the $5 million maximum is reached, no additional benefits are payable.

Managed Care Plan
Health insurance plan which generally provides comprehensive services to their members (“enrollees”), offering financial incentives for patients to use their participating providers in a specified network. HMO and PPO plans are both examples of a managed care plan.

Network Provider
Physicians, hospitals or other providers of medical services that have agreed to participate in a managed care network – offering their services at discounted rates and meeting other negotiated contractual provisions. They are also sometimes called “participating providers”.

Out-of-Pocket Maximum
The total dollar amount an insured person is required to pay for covered medical services during a specified period, such as one year. This may also be called the “stop-loss limit” or “catastrophic expense limit”.

Preferred Provider Organization (PPO) plan 
A health insurance plan where coverage is provided through a network of selected health care providers (such as hospitals and physicians) who have negotiated contracts with the insurance company to offer their services at discounted costs. Enrollees may go outside the network for care, but this would most likely incur larger costs to the enrollee (e.g.: a higher deductible or higher, non-discounted, charges from the providers).

Primary Care Physician (PCP)
The primary contact for enrollees within a health plan, this is often a family physician, internist, or pediatrician. In a managed care plan (e.g.: a HMO or PPO), a PCP monitors patient health, treats and/or coordinates most patient health problems, and if required by the plan, refers patients to specialists when necessary.

Prior Authorization
A review of the need for health care services or products, before services are rendered or products are provided. This term refers to a decision made by the health insurance plan provider to cover or not cover the charges before any services/products are provided.

Stop-loss Provisions
A contracted limit in a health insurance policy that provides for 100% payment of expenses after the total patient’s/group’s out-of-pocket expenses exceed a certain dollar amount.

Usual and Customary (U&C) Charge
The basis for how conventional indemnity plans operate. U&C charges is a term used for commonly charged or prevailing fees for health services within a geographic area.  A fee is generally considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community. This is sometimes also referred to as “Reasonable and Customary (R&C) Charge”. In contrast, PPO plans often operate on a negotiated (fixed) schedule of fees.

Wellness Office Visit
A doctor’s office visit not prompted by any sickness or injury.

Glossary References
http://www.bls.gov/ncs/ebs/sp/healthterms.pdf 
http://www.ehealthinsurance.com/health-insurance-glossary/terms-a/

Notice to Patients
Open Payments Database

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospital be made available to the public.

You may search this federal database for payments made to physicians and teaching hospitals by visiting this website: https://openpaymentsdata.cms.gov/

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