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FAQs about Out-of-Network Insurance, Self-Pay and Out-of-Pocket Cost for Insured Patients

Out of Network Insurance Plans

Why isn’t Midlands participating with my insurance plan? or Why did you leave the network?

The practice considers several factors when deciding whether to participate with a particular insurance plan. Those factors include the number of patients covered by the plan in our community; the rates the plan will pay for our services; and the administrative requirements the plan places on our staff to authorize and receive payment for the services we render.

What if my insurance plan tells me Midlands will be paid an in-network rate?

When an out-of-network plan says it will pay the practice an in-network rate, that means the plan will pay us less than the price we have set for the service. Our rates are fair and transparent, so we are not willing to accept less from an out-of-network plan.

Will you file my insurance even though you are out-of-network?

Yes. We will submit your claim to your insurance plan, but we also ask that you pay for services in full at the time of service. We will refund you any balance after your plan pays or credit it to a future service if you have one. Some plans require us to accept a discount if we receive payment directly from them. In those cases, we will ask the plan to pay you directly.

Self-Pay and Out-of-Pocket Calculations

Can I get an itemized billing statement?

If a bundled package was purchased, we cannot itemize. By definition, a bundle is a set of services offered for one all-inclusive price. We can provide an invoice that lists the services included in the bundled rate.

Do I have to purchase the package from the webpage?

If you are not able to purchase the bundle online with a credit card, we will accept payment at the office prior to your appointment.

Why do I have to pay ahead of time?

While we understand it’s hard to plan for unexpected medical issues, our rates are fair and transparent. We strive to provide as much information up-front as possible, so you do not receive large surprise bills after your care.

We require payment in advance because the care we offer is expensive to provide. Our physicians use expensive equipment and supplies to diagnose and treat patients. Our surgery center must purchase expensive implants for most surgeries before the surgery is performed. We incur those expenses before you receive the care, so it’s important for us to recover that cost.

We offer Care Credit to patients who need assistance with the pre-payment requirement. We can offer a pre-payment plan allowing you to pre-pay installments toward a surgery date in the future.

Why do I have to pre-pay when I have insurance?

If your insurance plan requires you to contribute to the cost of your care, we will calculate that amount based on your plan’s requirements and collect it from you prior to the service being rendered.

We require payment in advance because the care we offer is expensive to provide. Our physicians use expensive equipment and supplies to diagnose and treat patients. Our surgery center must purchase expensive implants for most surgeries before the surgery is performed. We incur those expenses before you receive the care, so it’s important for us to recover that cost by collecting the total amount due, not only the portion insurance pays.

Can I set up a payment plan for the pre-pay amount?

We can offer a pre-payment plan allowing you to pre-pay installments toward a surgery date in the future, but we generally do not set up payment plans for patient deductibles to be paid after a service has been rendered.

Factors that may influence this decision on a case-by-case basis include whether the surgery is elective; the patient’s payment history with the practice; our up-front cost to render the service; and the portion of the total payment due to the practice or ASC that is the patient’s responsibility versus the insurance plan’s responsibility.

I shouldn’t have to pre-pay because I have claims from other doctors that will meet my deductible before this surgery.

Insurance plans pay claims in the order they are received. We cannot guarantee that other claims will be submitted and processed prior to our claim. We will re-verify your benefits and expected out-of-pocket upon request prior to your payment.

Do you have any assistance programs to cover medical cost?

No

I have met my deductible. Why do I still owe money for this surgery?

Your insurance plan requires you to contribute to the cost of your care by paying a deductible and a percentage of the charges up to an annual out-of-pocket maximum. We are collecting the expected out-of-pocket amount based on information received from your plan.

Why can't I pay the day of surgery?

We require payment in advance because the care we offer is expensive to provide. Our physicians use expensive equipment and supplies to diagnose and treat patients. Our surgery center must purchase expensive implants for most surgeries before the surgery is performed. We incur those expenses before you receive the care, so it’s important for us to recover that cost. The surgeon and the ASC block out time in their schedules for your procedure, which makes that time unavailable to other patients. Pre-payment 5 days in advance is required to reserve that time for you. Surgery day is also busy and stressful. Pre-payment reduces the stress of the day and prevents your surgery from being rescheduled if you were to forget your payment.

If my insurance carrier states that I don’t have to prepay, why is Midlands asking for the prepay?

We only ask you to pre-pay the amount that your insurance plan has indicated you will owe based on your deductible, co-pay and/or co-insurance. We calculate your specific out-of-pocket estimate based on the rates your plan allows for the services and your specific plan benefits. If claims from another provider are processed before ours and that reduces your out-of-pocket responsibility, we will refund any balance due to you in a timely manner.

Will I be refunded if insurance pays and a credit is on the account?

Yes