• Read and understand your insurance benefits and, if you have more than one insurance, you must know what coverage is expected from each.
• Call your insurance company to verify and/or explain anything you do not understand.
• If possible, get a response from your insurance company in writing.
• Write down the name of the person you talked to, their phone number, what they said, and the date.
• Be sure to bring your most current insurance card with you to your appointment. If you have multiple insurances, be sure to clearly indicate which is primary. We cannot deal effectively with your insurance company without accurate information provided by you.
• Be sure you know when you need to have a referral and bring it with you when you come for your appointment.
• If your insurance requires pre-authorization, be sure you tell us this.
• Talk to our billing office before you have surgery if there are any problems or if you have any indication that your surgery will not be covered.
• Be prepared to pay the portions of your bill that your insurer says are your responsibility. Generally this is your copay, deductibles, and noncovered and/or excluded services.
• If you know that payment of your bill is going to be a problem for you, you must discuss this with our billing office before you have surgery.

Do you accept my insurance?

Our patients frequently ask this question, and unfortunately we cannot always tell you! What seems like a very simple question is really very complex. There are not always hard and fast answers.

Here are some of the reasons why:
The final decision about participation comes from your insurer. We do not have any control over this decision. Sometimes your insurer has information we do not have. Sometimes they make mistakes.

There are hundreds of insurers doing business in the Chicago area. Many of these companies have multiple plans. Some plans are customized for a particular employer. So, for example, although we may have a contract with “Insurer A”, they may handle multiple companies, each of which offer multiple products, some of which we are allowed to participate in and some that we don’t. Multiply the number of insurers times the number of plans they offer, and I think you can see why in a large metropolitan area like Chicago it is not possible to stay on top of plan designs and their frequent changes.

The good news is that we are familiar with the larger companies that we deal with on a regular basis, and we can tell you a good deal about them.

Our contracting is done by our PHO (Physician Hospital Organization). The reason for this is so that insofar as possible we can try to coordinate the doctors’ participation with hospital participation, so you do not face a situation where your doctor bill is covered but your hospital bill is not. Our office has little control over contracting matters.

We are dependent on the insurers and the PHO to keep us current on the status of each contract. This does not always happen in a timely way. We do our best to stay on top of this, but there are unavoidable errors that occur. There is not a month that goes by without 2-10 insurance changes to track, and we are not always given accurate or complete information.

There is also the matter of plan exclusions. There may be many reasons for this, among them:

• Pre-existing medical conditions
• Noncovered services
• Pre-certifications
• Need for referral from a primary care physician
• New procedures (insurers call them experimental)
• Care deemed unnecessary (as determined by your insurer)

Much of this probably sounds difficult, but it is good information to refer to when things don’t go smooth. However, most of the time there are no payment problems!

How much should I expect to pay?

Again, you should call your insurance company and get this information directly from them. Most companies have member service representatives whose sole job is to explain these matters to you. Since they will ultimately be making the decisions, it is important to talk directly to them about your specific situation. We can, however, give you some general information that may be helpful to you.

In most cases, there is a portion of your medical fee that is payable by you according to the terms of your insurance. Our contract with your insurance not only specifies that we agree to a particular payment from the insurance company, but also that we must bill you for your portion. If you expect that paying this may be a problem for you, you must make arrangements with our billing office before you have surgery. One of the reasons for this is that federal law recognizes any discount that is given on a bill to you after the service is rendered as a rebate, which is then taxable income. If the arrangement is made prior to the service being rendered, it is then a discount and there is no tax impact.

Sometimes when insurance problems occur people tell us: “It’s your responsibility to collect from my insurance. That has nothing to do with me.” This is not true. When you come to a doctor’s office to request medical care, you enter into a contract with the doctor to provide a particular service for a particular price. This contract is between you and the doctor, and is totally separate from your insurance. You and your insurance company have another contract. You have paid a premium for the expectation of having certain medical care paid for according to the benefits of your plan. Your insurance company, under contract to you, then makes payment on your behalf. This is totally separate from your contract with your doctor. To simplify the process of payment, we bill your insurance company on your behalf as a courtesy, and delay sending a bill to you for a reasonable period of time to allow your insurance to pay. If the insurance does not pay appropriately, it is ultimately your responsibility to either make payment personally or see that your insurer does this. We routinely help with this, but it is clearly not our “responsibility” to do so.

What do I do if I want you to do my surgery but you are not in my plan?

We actually treat many patients that have only out-of-network benefits. Many of them are surprised at how little the difference is in actual dollars once they have investigated the benefit. Others feel that, since surgery is a rare occurrence in one’s lifetime, it is money well spent to pay a bit more for the peace of mind that knowing you are being treated by top surgeons gives.

Many insurance plans now are being written to include benefits for out of network providers. You can expect that you will need to pay a larger out-of-pocket amount for care rendered by doctors who are not in your network. You should find out ahead of time if your surgery will be considered in-network or out-of-network and what your portion of the bill is expected to be.

Some insurance plans do not have any out-of-network benefits at all. This is a more difficult situation that will likely leave you responsible for the entire bill. If this is the case and it would be difficult to pay the expected amount, you should talk to our billing department. We have had this situation before, and are happy to make payment arrangements whenever this is possible for our needy patients.

If you need to be hospitalized, however, you also need to consider whether or not Rush-Presbyterian-St. Luke’s Medical Center is in network. In most cases the hospital bill is going to be significantly higher than the surgeon’s bill will be, and it is best to get an estimate of this as well. Rush does hold some contracts that the doctors do not, so do not assume that the same situation applies. Our billing office will help you to contact the right people at Rush to discuss this.

Our office is committed to making available the best possible medical care to anyone who honestly requests it. This means that, should you find that your insurance does not provide a benefit you can afford, we are always willing to discuss this with you and to make arrangements that will fit your circumstances.

List of insurance contracts