Health Plan Participation
We are pleased to participate with most major health plans. When visiting our office, please bring your most current insurance card to ensure the information is valid. Incorrect or out-of-date information will delay processing of your claim, and you may be responsible for payment in full.
Do I require a referral to see Dr. Yeaney?
If you have an HMO plan, you will probably require a referral from your Primary Care Physician (PCP). If you have a PPO plan, you probably do not require a referral. Regardless of what type of plan you have, if you are under the care of a PCP you should discuss your situation with him/her because the PCP will understand the requirements of your Health Plan and the PCP is often the one required to make the referral. If you do not have a PCP, or you still have questions, please call the member services number on your insurance I.D. card.
What happens if I do not have a properly authorized referral before I see a Dr. Yeaney?
There are several problems that could arise if your referral is not properly completed with any required prior authorization before you receive services at The Vascular Group of Bradenton. While health plan rules vary, here is a sample of what may happen:
- Your appointment with the physician or service may be delayed until the referral is made/properly authorized.
- For some health plans, you may be responsible for payment of the bill.
Will I be required to pay anything when I arrive at the office?
You will be required to pay any applicable copayments, coinsurance and deductibles. If the service is not a covered service, you will be responsible for the amount in full.
Should I bring my insurance card with me?
Yes, the information on your insurance card is needed in order for The Vascular Group of Bradenton to file a claim with your insurance company or companies. When you register, we will ask for information about your insurance coverage and have you sign a few forms. This registration process goes much faster when you bring your insurance information with you.
Do I need to let my insurance company know that I will be visiting a specialist? What will they cover?
Because there are so many types of insurance plans, it is difficult for us to tell you whether or not you need prior approval or notification for your visit. Contact your insurance company with specific questions about what is or is not covered by your insurance plan.
How do I know if my insurance company will cover my visit or certain services?
Coverage varies with each insurance company. Medically necessary and appropriate services may not always be covered by your insurance contract. Please refer to your insurance member handbook or call your insurance company with questions.
Will you bill my insurance company for me?
Yes, as a courtesy we will bill your insurance company. It is your responsibility to provide any requested information to your insurance company (accident information, claim forms, etc.).
How will I know if my insurance company has paid my bill?
If there is a balance due from you after the insurance company has paid its portion, we will send you a statement. This statement indicates the amount that has been paid and any balance you are required to pay. This is your bill. You are required to pay this bill in full.
What do I do if I disagree with how much my insurance company has paid on my bill?
If you disagree with the insurance company’s payment amount or whether or not they cover a service, contact the insurance company and ask them to review how the claim was processed. If the insurance company finds that an error was made, note the information and whom you talked to at the insurance company. Request an anticipated payment date and ask if they need anything from you. If the insurance company feels the bill was paid correctly and you still disagree, find out from the insurance company what you need to do to file an “appeal” with them. Filing an appeal will not guarantee that the insurance company will pay more on your bill, but the claim will be reviewed for reconsideration.
Glossary of Insurance Terms
Coinsurance – A provision in a member’s coverage that limits the amount of coverage by the plan to a certain percentage, commonly 80%. Any additional costs are paid by the member out of pocket.
Copayment (Co-Pay) – That portion of a claim or medical expense that a member must pay out of pocket. Usually, a fixed amount such as $30.
Deductible – That portion of a subscriber’s (or member’s) health care expenses that must be paid out of pocket before any insurance coverage applies, commonly $1,000-$2,000. May also apply only to one portion of the plan coverage (ex. Radiology services).
Explanation of Benefits (EOB) – A statement mailed to a member or covered insured explaining how and why a claim was or was not paid.
Formulary – A listing of drugs that a physician may prescribe.
Gatekeeper – An informal term that refers to a Primary Care Physician. All care must be authorized by the Primary Care Physician before rendered.
Health Maintenance Organization (HMO) – A licensed health plan (licensed as an HMO) that utilizes designated (usually Primary Care) physicians as gatekeepers.
Member – An individual covered under a managed care health plan. May be either the subscriber or a dependent.
Non Par – Short for nonparticipating. Refers to a physician that does not have a contract with the health plan.
Preferred Provider Organization (PPO) – A plan that contracts with independent providers at a discount for services.
Pre-certification – The process of obtaining certification or authorization from the health plan for a visit to the specialist or for routine hospital admissions.
Primary Care Physician (PCP) – Generally applies to internists, pediatricians, family physicians and general practitioners.
Subscriber – The individual or member who has health plan coverage by virtue of being eligible on his other own behalf rather than as a dependent.