HMO, POS, or PPO Insurance
Patients with HMO, POS, or PPO coverage are responsible for paying any co-payment, deductibles, co-insurance, or fees for non-covered services at the time the services are rendered. Full payment of co-pays is requested before services are rendered. To help you get the most from your health plan, we encourage you to familiarize yourself with your insurance plan’s requirements prior to seeking care. Since employers negotiate their own contracts with insurance companies, plans can differ significantly. Each patient has a responsibility to know and understand his or her individual benefit package. A common example is a $75.00 co-pay that a number of contracted payers have for emergency room visits. Your plan may be higher or lower than our example.
“Medical Necessity” is a term that has been used in recent years by Medicare and may not be familiar to you. “Medical Necessity” means that there are procedures and services physicians may prescribe for you that they may feel are necessary to manage your health. However, Medicare may not pay for certain services based upon their policies.
In the past, Medicare has covered most procedures. With the emergence of MRI, CT scan, and other sophisticated and costly services and procedures as the diagnostic methods of choice, it is important for you to know what procedures and services will be covered by asking your physicians and/or Medicare. We also encourage you to discuss with our physicians other treatment options available to you that may give them the information that they need to treat you.
If your physician orders a procedure or service that Medicare may not cover, you may be asked to sign an Advance Beneficiary Notice (ABN). The ABN informs you in advance that Medicare is not likely to pay for the procedure or service, and that you will be responsible for payment. By signing the ABN, you are indicating that you understand and agree to be personal and fully responsible for payment.
Do you have any options?
You can agree to be financially responsible for the procedure by signing the ABN form, or you can refuse the tests or services. If you refuse the tests or services, you will also be asked to sign a form indicating you’ve elected not to have the service. If you request the services and will not sign the ABN, you will still be responsible for payment.
If you need services that are not covered by Medicare, you will be responsible for payment. You have the right to appeal a Medicare decision not in your favor. If you would like to appeal a Medicare decision or have other Medicare questions, please contact the Medicare beneficiary hotline at 800-633-4227.
Services Not Billed
It is also important for you to know that the physician services you receive in the hospital are not included in the hospital’s charges. Physicians who provide services at the hospital may be independent voluntary physicians or they may be employed by the hospital. Physicians bill for their services separately and may or may not participate in the same health plans as the hospital. You should check with the physician arranging your hospital services to determine which plans that physician participates in.
Garnet Health Medical Center contracts with a number of physician groups, such as anesthesiologists, radiologists and pathologists, to provide services at the hospital. We will give your insurance information to these providers. If you have any questions about their bills, contact them directly.
Examples (partial listing) of separately billed services:
- Your physician/surgeon
- Other consulting physicians' fees
- Emergency physicians (Physicians who provided emergency room services)
- Radiologists (Physicians who read and review X-rays)
- Ambulance services
- Durable Medical Equipment (DME) providers
You should also check with the physician arranging for your hospital services to determine whether the services of any other physicians will be required for your care. Your physician can provide you with the name, practice name, mailing address and telephone number of any physicians whose services may be needed. Your physician will also be able to tell you whether the services of any physicians employed or contracted by Garnet Health Medical Center are likely to be needed.