How Does Health Insurance Work?

Your health insurance policy is a contract between you and the insurance company selected by you or your employer. Per the terms of their contract, the company has agreed to pay for all or some other medical expenses in exchange for the payment of premiums.

You or your employer decides what percentage of those premiums you pay each month. The premium amount (cost of health insurance) usually varies with the amount of medical expenses that are covered. Premiums may also vary depending on your health and age. Generally the more items that are covered and the greater percentage of medical expense costs that are covered, the higher the premium

There are many health insurance companies in operation today. And each company may have multiple plans for healthcare coverage, such as an HMO (health maintenance organization), PPO (preferred provider organization), or POS plan (point of service).

Additionally, within each health plan, there are multiple different policies, each with a different level of deductibles, varying co-pays, and differing covered services. Once again, the amount of expenses that are covered is determined by the plan and premium that you or your employer are willing to pay. 

What Do I Need to Know About My Insurance Before Visiting?

Since there are so many different plans and insurance policies available today, it is up to you to understand your policy, your deductibles, what is covered or not covered, and the other details of your plan. Even though we try to determine your health insurance coverage at the initial visit and additional visits, often we must wait until after to find out the extent of your coverage from your health insurance company. You may receive a bill later for services that were not covered.

What is a Covered Service?

As noted above, the details of your health insurance policy include what medical expenses will be paid for (or covered) if you need them. Some services, such as surgery or tests, are usually covered. Other services - such as therapy, orthotics or certain medications – may not be covered. Services may also be partially covered or paid for at a certain percentage of the total cost. 

For example, you may be responsible for 25% of the total cost of the service while the insurance company pays the remaining 75%. The extent of coverage and the number of items covered are determined when you or your employer choose the particular plan.

If payment for a particular medical service, such as orthotics, is denied by the health insurance plan because it is a “non-covered service”, appeals by you or by us are not successful in persuading the insurance company to pay for it. An analogy would be your automobile insurance. If you did not purchase glass protection as part of your policy, the auto insurance company will not pay to replace your windshield when someone throws a brick through the windshield or it simply cracks. In this situation, you are responsible for paying for the medical service.

When is a Service “Medically Necessary"?

Medical services (office visits, status check-ins, surgery, therapy, etc.) that are prescribed by your physician for your particular medical problems are considered by your doctor to be medically necessary for the evaluation or treatment of her condition. We are simply practicing proper medical care when we ordered the services. 

The health insurance company may disagree with the necessity of providing this particular service, according to some protocol or policy. Often these policies are flawed or do not take into account or anticipate the specifics of your case.

If a service is denied due to “lack of medical necessity”, the health insurance company must notify you by writing. You then have the ability to appeal this position. Check with your insurance company at that time to learn about their appeal process. We can assist by providing copies of your office records or a letter restating the reasons for providing the service.

What is a Referral?

In certain plans, you are required to see your family physician or primary care physician (PCP) for an initial evaluation to determine that you require the services of a specialist (such as us). Under such plans you will be sent, or referred, to us to comply with these specifical insurance requirements. It is your responsibility to know if you require a referral to see us. Failure to obtain the required referral prior to being seen at the office visit may result in us not being able to treat you or requiring an out-of-network payment from you at the time of the service.

What is a Copay?

A copay is an amount that you are required to pay for a particular medical service, such as office visit or therapy visit. For example, you may be required to pay $10 at each specialist office visit or $15 for each regular prescription. The type of plan you or your employer has chosen determines this amount. By law and by our contract with the insurance company, we are required to collect your copay at the time of service. You are responsible for knowing what your copay is and paying at the time of service. Failure to pay your copay at the time of service will result in a $6 service charge.

What is a Deductible?

According to your health insurance plan, you may be required to pay a certain amount of your medical expenses each year. This amount is called your deductible. You will have to pay your deductible amount for medical services in full before insurance coverage of expenses begins. For example, if your deductible is $500, you will pay the first $500 spent each year on any medical service and care. Medical services after that are covered or paid for by your insurance according to your plan. (The insurance may pay all of the further medical expenses or a certain percentage.)

If you have not met your deductible for the year, you may be responsible for the entire amount of your office visit charge. After we bill your insurance company, they will notify us of your responsible amount.

What is an EOB?

When we bill your insurance company for services provided to you (office visits, surgery, etc.), we submit our charges, which are our prices for those services (based on our costs and national price guidelines).

The insurance company will send you and us a statement called an Explanation of Benefits (EOB) detailing the services provided and their payment towards them (i.e. your coverage). This payment is made to us and is based on the allowed amount - a discounted payment amount that we have negotiated with the insurance company as part of our contract with them.

In many cases there is little or no negotiation on our part; it is usually take it or leave it on their part. This is why doctors occasionally drop out of participation with a certain plan; usually, the allowed amount is less than our cost of providing the service.

Ultimately, the insurance company deducts any copays, deductibles, or percentage of the allowed amount that you are responsible for and sends us the insurance amount. This is what they actually paid us. Any remaining balance of the allowed amount is the patient responsible amount, which is the patient account balance that you receive as a bill.

If this number is different than you expect, sometimes a service will have been denied (not paid for) by the insurance company. This will raise the amount you are responsible for. This is unfortunately done after we have already provided the service to you (nice, huh?).

The reason for an insurance company denial is usually noted by a small notation mark or letter next to the service. The code to explain that reason is usually on the back of the EOB. Some insurance denials may be appealed and reversed. Contact your insurance company through the 800 number on the back of your card about their process for appeal.

For questions about your EOB, you can:

  • call your insurance company
  • talk to Renee at (724)-933-3300
  • contact Renee through your Patient Portal

What is Usual, Customary and Reasonable (UCR)?

Our charges or prices for medical services are based upon a national survey of physician reimbursement for our specialty and our region. We are currently in the “middle o’ the pack” with regards to our charges, despite Dr. Bowman’s position as both the most experienced foot and ankle surgeon in the tri-state area and one of the most experienced hand surgeons.

Insurance companies, however, have developed an arbitrary fee schedule or price list for medical services called Usual, Customary and Reasonable (UCR). This fee schedule is often different than our charges and does not take into account the actual cost of providing medical care. Notice there is no UCR for insurance premiums.

What is “Non-Participating” or “Out Of Network”?

Since insurance companies are still mostly regulated by states and the government has not allowed them to operate across the country, most insurance companies operate within a certain region. In that region, they will sign a contract with certain doctors and hospitals to provide medicals services for their customers, or enrollees. This group of doctors and hospitals is called their network.

This network is usually developed in order to obtain discounts or reduce costs for the insurance companies, and is not based solely on quality. Doctors and hospitals that have do not a contract with that particular insurance plan are considered out of network or non-participating. This is usually because the doctor or hospital is out of the insurance company’s operating region. In other cases, the doctor or hospital chooses not to have a contract with (participate with) that plan. The most common reason for this choice is inadequate reimbursement.

What does this mean for you? Your insurance company will usually pay a different percentage for the medical expenses provided by in or out of network doctors/hospitals. For example, out of network expenses may only have 50% coverage, while in network expenses may have 85% coverage. (Your insurance plan network policies may affect you while away on vacation as well. Be sure to check them!)

We treat many patients from other states and even other countries. We are experienced at working with out of network patients since we cannot participate with every plan. We can also work out a payment plan, if necessary. However, you are responsible for checking to see if we are in your network plan. Contact Renee at (724)-933-3300 if you have questions after speaking with your insurance company.

What are Global Fees?

For some who are defined medical services such as surgery, the insurance companies bundle the associated charges together into a package known as a global fee. This lumps together our surgical charges with all postoperative office visits for a certain period known as the follow-up day (FUD) period (which usually lasts 90 days). You will not usually be charged for office visits during this period.

The FUD period may vary slightly between insurance companies or for different surgical procedures. X-rays, medicines, and certain supplies are not included in the Global fee. If you are evaluated or treated for a different or additional problem while in the FUD period, there will be an additional charge for those services.

What Insurance Plans Do You Accept?

One of the advantages Pittsburgh Foot and Hand Center offers by remaining an independent private practice is the ability to work within both the UPMC and West Penn Allegheny General health systems. We are able to accept and treat patients covered by most insurance plans. 

Enclosed below is a list of insurance plans for which Pittsburgh Foot and Hand Center currently has a contract as a preferred provider. Many insurance companies issue multiple plans with different provider lists, however, so check your planned provider list or call the 800 number provided on your insurance card to verify whether we are “in network” or out of network providers for your specific plan.

 If your foot or hand problem is from a workers compensation injury, please review the section on workers compensation injuries. Companies frequently change their provider panels without notifying us. If your foot or hand problem is due to an injury or is the result of a motor vehicle accident, motorcycle accident or involved in litigation, please review the section on auto/motorcycle accident and litigation injuries.

We are experienced in treating patients from out of state and without in-network insurance plans. Often we are able to work together to obtain coverage from your plan. We may also treat patients who are currently without insurance by treating them as self-pay accounts.

What Do I Need to Do if I Was Injured at Work and Covered by Workman’s Compensation Insurance?

When you are injured at work or become sick as a result of your workplace or work requirements, you will usually be covered for any related medical expenses and any lost wages through your employee’s Workman’s Compensation (WC) insurance plan. Workman’s Comp has some very unique and rigid policies. Failure to comply with them may result in you becoming responsible for all of your medical expenses. 

When you are injured or sick because of work, you are responsible for promptly notifying your employer about the situation. The employer will then file an injury report and claim with the WC insurance company. They will acknowledge receiving the claim or issue a Notice of Compensation Payable (NOCP). This is not a guarantee that they will cover the expenses. Unfortunately, WC may deny payment for expenses even after surgery and after they initially paid medical expenses or your wages.

Usually, your personal health insurance will not pay for work-related medical expenses unless WC denies the claim. During treatment for WC injuries, we will bill the WC insurance directly. You will not have to pay for related expenses unless WC denies the claim. For this reason, we also get your personal health insurance information. We do not submit a claim to your personal health insurance unless there is a WC denial. In case of a WC denial, we must file a timely claim with your insurance or they may also deny coverage. In this situation, you may be responsible for all charges!

To help you avoid these types of problems with WC, Pittsburgh Foot and Hand Center has adopted certain policies concerning WC cases. See our Financial Policy to learn more.

What Do I Need to Know About Automobile/Motorcycle Accident and Litigation Injuries?

If you have been injured in an auto or motorcycle accident in which your automobile/motorcycle insurance is responsible, we will obtain both your auto/motorcycle insurance and your personal health insurance information. Automobile/motorcycle insurances have a set cap on the amount of medical expenses they will pay for each accident. This includes your emergency room visit and other related costs. This cap was predetermined when you selected and purchased your insurance. When the cap on medical expenses is reached, the insurance company will deny any further claims or payment. At this point, your auto/motorcycle insurance is exhausted.

Note that we do not know how much of your auto/motorcycle medical benefits have been used at your initial visit. After you assign the benefits to us, we will bill your auto/motorcycle insurance first and your personal health insurance second if your auto/motorcycle insurance is exhausted. If you do not have personal health insurance, then we will treat any patient account balance remaining when your auto/motorcycle insurance is exhausted as a self-pay account for which you are responsible in full. If you choose not to assign the benefits to us, then your account will be considered a self-pay account and you will be financially responsible in full at the time of service.

Automobile/motorcycle accidents in which someone else’s insurance is responsible – or injuries where someone else is responsible (litigation) – are handled differently. You must provide us with all of the accident information, including the other individual’s auto/motorcycle insurance information and contact information as well as your personal health insurance. As a courtesy, we will bill the other person’s auto/motorcycle insurance first if you assign the benefits to us. We will bill your personal health insurance second after the other person’s auto/motorcycle insurance is exhausted. If you do not have personal health insurance, you will be responsible for all remaining charges when their auto/motorcycle insurance is exhausted. All charges are payable when the service is provided. 

We do not accept assignment from lawsuits (litigation) or letters of cover from attorneys as payment. All charges are payable when the service is provided. We will bill your personal health insurance as a courtesy if you assign the benefits to us. The insurance company will be reimbursed out of any settlement of your litigation.


How will I be Billed for My Care?

You are responsible for paying any co-pays and known deductibles during your office visit. As a courtesy to you, we will fill out the necessary forms and bill any remaining charges directly to your insurance company. You will be asked to sign an insurance waiver form, directing your insurance company to pay the remaining balance directly to us.

You will next receive an Explanation of Benefits (EOB) from the insurance company, explaining what they paid. If the insurance company denied coverage for a service or pays only a certain percentage of the allowed amount, you will receive a statement from us noting your patient account balance - the amount that you are responsible for. We will send this billing statement each month to your home or designated address. We can send this to you by mail and or through your designated Patient Portal.

For patient account balances delinquent past 90 days, we may send your account to a collection agency, unless you arranged a payment plan with us. Failure to pay your patient account balance may prevent us from caring for you in the future.

How can I Pay My Account Balance?

We accept cash, personal checks, money orders, and most major credit cards or debit cards for payment of your copays, deductible, and patient account balance. You may pay in person at your visit, by mail, or online by going to Pay Bill Online. You may also arrange for a payment plan, if necessary, by contacting Renee at (724)-933-3300 or through your Patient Portal.

Are Payment Plans Available?

If you incur a patient account balance with Pittsburgh Foot and Hand Center, contact Renée in our office at 724-933-3300 to discuss establishing a payment plan. We will send you monthly statements through the mail or through your secure Patient Portal.

We accept cash, personal checks, and major credit cards or debit cards for payment. If you agree we will securely maintain your credit card information on file for automatic payment of your patient account balance. Please fill out and return the Easy Pay Consent Form.

You may also pay any patient account balance online by establishing a secure Patient Portal. You then simply click on Pay Bill Online to submit your payment. We will send your statement and receipt of payment through your Patient Portal.

How can I Contact Someone About My Insurance/Billing?

We usually advise you to check with your insurance company first with questions about their policies. You can do this by calling the 800 number on the back of your card, checking their website, or reading the booklet you received with your plan. You may also contact our billing specialist Renee at (724)-933-3300 or through your Patient Portal.