Insurance

We take most insurance plans. Please call your insurance company to find out if we are an in-network provider for your specific plan. As a courtesy to you, we will submit your claim for your visit or procedure to your insurance company. Your insurance company determines what portion of the claim they will cover. If you receive a bill from us or from a lab for testing done with us and expect that your insurance company should have paid it, please call your insurance company directly to dispute.

It is your responsibility to know what coverage your insurance company allows. Financial responsibility for our services rests with the patient, regardless of insurance coverage. We advise you to know your copay and deductible when you make an appointment so you understand your financial responsibility to us. We have put together some commonly used healthcare insurance terms so you may better understand your healthcare responsibility.

Referrals

Many insurance plans, especially HMO plans, Tricare and MassHealth Standard, require you to receive approval from your primary care physician (PCP) before you see a specialist. Verify with your insurance company whether you need a referral for the type of visit/service you are seeking. If you do need a referral for your insurance plan, please call your PCP’s office to request one before you schedule an appointment with us. Please let us know when you schedule your appointment that a referral is required and you have requested it.

Prior Authorization / Precertification

Prior authorization refers to a requirement by health plans for doctors to obtain approval of a health care service or medication before the care is provided. This allows the plan to evaluate whether care is medically necessary and otherwise covered. The process for obtaining prior authorization also varies by insurer but involves submission of administrative and clinical information by the treating physician.

Deductible

Your deductible is the amount you pay for covered healthcare services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.

Co-Payment

Your co-payment is a fixed amount ($20, for example) you pay for a covered healthcare service after you’ve paid your deductible. Let’s say your health insurance plan’s allowable cost for a doctor’s office visit is $100, and your copayment for a doctor visit is $20.

• If you’ve paid your deductible: You pay $20, usually at the time of the visit
• If you haven’t met your deductible: You pay $100, the full allowable amount for the visit.

Coinsurance

Coinsurance is the percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible. Let’s say your health insurance plan’s allowed amount for an office visit is $100 and your coinsurance is 20%.

• If you’ve paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest.
• If you haven’t met your deductible: You pay the full allowed amount, $100.

Out-of-Pocket Maximum/Limit

This is most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits.

The out-of-pocket limit doesn’t include your monthly premiums. It also doesn’t include anything you spend for services your plan doesn’t cover.