Billing and Insurance
insurance and or billing questions not answered below or questions
regarding your account, you may contact our Customer Service Call Center @
713-520-4700. Billing representatives are available to assist you
Monday through Friday from 9:00 am – 4:30 pm.
courtesy to you, the Clinic will verify your health insurance coverage and
benefits as well as file a claim with your insurance carrier once medical
services have been rendered. To assist us with this service, please
contact our registration representatives at least 24 hours in advance of
your appointment (if you haven’t done so already) at 713-526-5511, x 4624,
to provide us with your health insurance plan information.
We encourage payment for services rendered
at the time of your visit, including payment of
applicable deductibles and co-pays. We accept payment by cash,
check, VISA, Master-Card, Discover, and American Express.
Indemnity Insurance and Self-Pay: Since your insurance policy
is a contract between you and your insurance carrier, we do not guarantee
payment of your claim, nor do we assume responsibility for meeting your
insurance plans’ requirements for pre-authorizations, second opinions, or
hospital stays. We will, of course, be happy to furnish you with any
documentation needed to obtain necessary approvals or to resolve a disputed
PPO and POS plans:
Payment of applicable deductibles and co-pays should be made at the time of
your visit. We will submit a claim to your insurance carrier for
direct payment to the Clinic of your insurance benefits. We make
every effort to be aware of obligations under your plan for
pre-authorization, referral authorizations, and other utilization
management obligations in order to be able to provide the services you need
based on your health status. Your awareness of your plan's
requirements will add a greater level of assurance that your plan’s
obligations will be met which, in the long run, will benefit you. It
is important for you to know that your insurance plan may not pay for all
services provided at the Clinic. What is covered is dependent on your
plan’s benefits. You will be responsible for all services rendered
that are considered non-covered, experimental, or deemed by your insurance
company as not medically necessary.
HMO and gated plans:
If your health plan requires you to select a primary care provider (“PCP“)
please contact your Plan Administrator to designate your MCH general
internal medicine physician as your PCP at least 24 hours in advance of
Medicare: Original (often called traditional) Medicare
is a health insurance program administered by the U.S. government for
people age 65 or older and for some disabled persons under 65. It is
divided into two parts: hospital insurance (Part A) and medical insurance
(Part B). We bill Part B insurance when services are rendered at the
Clinic or by a Clinic physician.
MCH physicians have chosen
to be in the participating category of physicians in the Original Medicare
program, which means your MCH physician will accept Medicare
It is important for you
to know that Medicare does not pay for all services provided at the
Clinic. Medicare may determine your diagnosis does not qualify for
coverage for certain procedures (e.g., limited coverage procedures) or that
you have had a test too recently. You may be asked to sign a waiver
[i.e., a Medicare Advanced Beneficiary Notice (“ABN”)] stating that you
will be responsible for payment should Medicare deny payment.
Medicare also does not
pay for "non-covered" services, which are services that fall
outside of the Medicare program. Physicians, whether
"participating" or "non-participating," can bill their
usual fee for non-covered services. You will be responsible for full
payment of non-covered services.
Medicare Replacement Plans: Medicare also offers Medicare
Advantage plans through various for-profit insurance companies. The
ONLY Medicare Advantage plan patients our physicians will accept will be
those patients covered by the Aetna Teachers’ Retirement Medicare Advantage
plan (TRS.MA), effective January 1,2013,
be aware that the Clinic does NOT participate in Medicare Advantage (HMO
or PPO) plans or accept Medicare
Advantage patients. As an exception to this policy, the Clinic has
agreed in principle to see Aetna Teachers’ Retirement Medicare Advantage
patients on an out-of-network basis.
How Can I Claim Benefits? The Clinic will
complete and submit medical claim forms to Medicare and one secondary
carrier for services rendered at the Clinic or by a Clinic physician.
Generally, the Clinic is directly reimbursed for 80% of Medicare's allowed
amount minus your unmet deductible. A claim will be filed with your
secondary insurance company, if any, after Medicare pays. You will be
responsible for the remaining balance (the "co-insurance"), plus
any part of the deductible you may owe. All clinical laboratory
services are reimbursed at 100% of the amount approved for each test.
For clinical laboratory services only, no deductible or co-insurance is
required of you, as long as the tests are deemed by Medicare to be
medically necessary and provided within required timeframes.
Payment for specialized procedures
Advanced procedures: Patients scheduled for certain
procedures including, but not limited to, CT Scans, MRIs, Nuclear
Cardiology Studies, Echocardiograms, and Sleep Disorder Studies will
be responsible for making payment arrangements for the self-pay portion of
the study prior to the test being performed. This includes the
estimated amount that will be owed due to your annual deductible,
coinsurance, non-covered services, frequency limitations, or lack of
Cardiac Score Scans: Patients are required to pay for
Cardiac Score (heart) scans at the time of service.