Insurance and Billing

Commonly asked questions:

Do I have to pay at the time of my visit?

Generally all applicable fees are due at the time of services provided unless other arrangements have been made in advance.  Most insurance plans have out-of-network benefits that we can work with in order to minimize your out-of-pocket costs.  As a courtesy, we will gladly bill your insurance company so that you may get reimbursed according to the specific coverage afforded by your insurance plan.

We know how confusing insurance plans can be.  If you have any questions, feel free to ask us.  We may be able to help.

Do you “take” insurance?

While we are not contracted with any medical insurance plans, we will work with patients’ out-of-network benefits and submit our bill to their insurance company for any reimbursement as provided for by their plan.

If a doctor is not on or contracted with my preferred provider insurance (PPO) plan, can I still see that doctor?

Absolutely.  Many people are under the mistaken impression that if one of our doctors is not “on their plan,” then they “cannot see the doctor.”  This is not true.  It is very important to understand that one always has the right and ability to see our doctors even though we are not contracted with any insurance plans.  Our billing department will work with all patients to provide value for the cardiac evaluation or testing provided at our offices.  We will work with whatever out-of-network benefits are provided by your insurance plan.  We are happy to go over fees for consultative, diagnostic, testing and on-going care services which most patients realize provide value for their specific situation.

We can tell you that most of our patients with PPOs that we have previously ceased being preferred providers of have found value and comfort in continuing to get attentive and personal care with our office (a few did briefly go elsewhere only to return to see one of our doctors as they realized they felt more comfortable in our office even if the cost was modestly higher than with other “contracted” doctors).  In fact, many patients from all over the country (and world including Royal Family members and government officials) with insurance that we are not contracted with have come to our doctors for second opinions as well as routine cardiac care.

How does billing work in your office since you are “out-of-network”?

Our billing department will work with all patients to provide value for the cardiac evaluation or testing provided at our offices.  We are happy to go over fees for consultative, diagnostic, testing and on-going care services which most patients realize provide value for their specific situation.

It is important to note that our office will still submit the proper insurance claims and filings for our patients at no charge. We can provide patients with billing codes to assist them in their contact with insurance companies regarding reimbursement details. We DO NOT intend this to be an unreasonable financial burden for our patients and will work with them to make their out-of-pocket expenses affordable.

If you have any questions, please to not hesitate to call our billing specialists directly.  We are available to answer any financial-related questions you may have, as well as further explain why we believe our policies allow us to maintain our high level of care.

Do you accept credit cards?

Yes.  We accept American Express, MasterCard and Visa.

Do you still accept Medicare?

Yes.  If the patient has a secondary or supplemental insurance plan, then we will bill that plan in addition to Medicare for the patient.  However, the patient is responsible for all co-payments and deductibles not covered by Medicare or their supplemental plan (unless otherwise specified) up to the Medicare allowable limit.

Please note that this holds true for patients with traditional Medicare and Medicare supplemental PPO plans.  In some cases, “Medicare Advantage” plans might be affected if we are out-of-network although arrangements can still be made to allow you to have medical care with our doctors.  If uncertain about your Medicare coverage, please speak to our billing staff so that we can continue to provide you care in our office.

 

Why is our office not contracted with any preferred- provider organizations (PPOs) or insurance plans?

Our goal is to offer the highest quality health care.  It is our belief that a contract with a third party is an inherent conflict-of-interest with our ethical obligation to the patient in providing the best care.

Given the current challenging health-care environment, it is our belief that our policy allows us to do so by charging reasonable fees and not be encumbered by insurance policies that often interfere in the physician’s ability to provide the best care possible for the patient.  This does not always mean more tests or fancier medications, but rather thoughtful and reasonable assessment and advice on the best way to diagnose or treat a condition.  When several options are available for the patient, then the doctors lay out these options with the pros and cons of each option.  The ultimate goal is that our physicians, with the patient’s input, formulate the best medical diagnostic and treatment plan for their patients’ individual situation.

The level of physician reimbursement from PPO’s has progressively dropped while the cost of providing medical care has continued to climb.  This has lead to the doctors being under more pressure to change the personal care that they have provided their patients.  Dr. Caren and Dr. Urman believe that it is that personal care that is essential in a doctor-patient relationship.  Perhaps insurance companies have attempted to provide care and benefits to more subscribers at lower costs.  But as the costs for medical testing, treatment, medications and hospital care has increased, the insurance companies have responded by decreasing payment to physicians (while charging you or your employer more!).  In addition, the insurance companies determine when, how, where and how often which services will be provided as well as how much providers will be reimbursed.  The situation has become personally unacceptable to Drs. Caren and Urman and they have come to view these circumstances as a barrier to the ability for them to provide the personalized medical care they strive to deliver.

Drs. Caren and Urman have come to believe that their only contract to provide the best possible medical care for the patient should solely be with… the patient.  Not with any third parties such as PPO’s as that poses an inherent conflict-of-interest to the doctor-patient relationship.  The doctors choose not to compromise the health of their patients or their doctor-patient relationships.

If you have any questions, please do not hesitate to call us and speak to the office manager, Ms. Liz Wagner, or our billing specialists directly.  We are available to answer any financial-related questions you may have, as well as further explain why we believe our policy allows us to best maintain our high level of care.  

Do you take HMO insurance?

No, but many patients in HMO’s have come to see our doctors in second or confirmatory opinions as well as for on-going routine or follow-up care.  While they have had to pay out-of-pocket for services, our billing department has worked with them to provide a reasonable and affordable situation that they feel provided them with great value for their care with our doctors.  In addition, some people have HMO plans that have “POS” or “point-of-service” benefits which allows some level of reimbursement to doctors out of the HMO network.  However, in these cases, the patient is responsible for paying all charges at the time of service although our office will submit the bill to the HMO for the patient.  The patient will be directly reimbursed by their HMO as per the coverage stipulated by their plan.  We do not accept Medi-Cal.

 

Definitions:

PPO:    a medical insurance company’s Preferred Provider Organization.

Preferred Provider:    A physician who has signed a binding contract with a medical insurance company to abide by not only the financial reimbursement rules established by the PPO, but also multiple regulations which often are not necessarily related to patients’ best interests.  In fact, in many ways, we feel these regulations are clearly detrimental to the doctor-patient relationship and pose significant challenges in this day and age for a doctor to provide the highest quality personalized medical care.  These regulations and rules for physicians who are “in-network” include (but certainly are not limited to) Byzantine referral processes, setting up roadblocks to keep patients from having tests that are medically necessary and trying to change medications that are effective for patients in order to increase the profit margins for the insurance companies. In addition, inadequate physician reimbursement policies worsen constraints on a doctors time and impede the practice of quality medicine. This indicates, at a minimum, that PPOs do not value doctors spending adequate time with each patient.  More recently, most PPOs have developed devious ways to avoid paying doctors after they provide services in good faith (and this is after the patient or his or her employer has paid them a lot of money for the policy).  We hope that you understand why this situation is unacceptable to us as perhaps it is to you.  By our choice to no longer be a preferred provider with a specific PPO, your doctor now is a “non-contracted” or “out-of-network” physician with that PPO.   Most importantly, that means that his contract with you, the patient, is not encumbered by any regulations that might not be in your best interest.

 

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