What is the difference between a PPO, HMO, MC (managed care plan), EPO, and a selections plan?

There are two categories of insurance plans available to patients. The Preferred Provider Option (or PPO) allows you to self refer to specialists outside of your primary care doctor without prior authorization from your insurance company. The HMO, MC, EPO and Selections plans fall into the managed care realm. They require you to have a Primary Care Provider or (PCP) registered with the insurance company and require referrals to seek care outside of your selected PCP.

What is a referral and how does it work?

A referral is a written order from your PCP and a pre authorization from your insurance company to seek care outside of your doctor’s office.

Can I see my specialist first and then call my PCP to authorize a referral?

No. The insurance companies require you to be seen by your PCP first. We are required to have documentation in your patient chart as to why outside care is needed before a referral is authorized by your insurance company. If you see your specialist before your PCP, a referral may be denied by your insurance and you will become financially responsible for the services rendered by the specialist.

What happens if I need emergency care and I have managed care insurance?

Referrals for emergent care are waived in most cases. You can be seen in the emergency room with no referral required. However, you will need to follow up with your physician before heading to the specialist.

My insurance made a mistake when I signed up during open enrollment and assigned me a PCP I don’t know or see. Can I still be seen by my regular doctor?

No. Not until the PCP is changed. If it is not changed prior to your scheduled appointment, you will be responsible for the cost of the office visit.

How do I change my PCP?

There is a customer service number listed on the front or back of your insurance card. Call this number and request the change effective immediately. The Managed Care plans will not “back date” your effective date so it is extremely important to take notice and take action. Once you have selected a PCP from our office, you can see any of our Physicians or Nurse Practitioners. The insurance companies recognize Bellevue Family Medicine as a “group”, which allows you more flexibility.

Why am I asked for my insurance card each and every time I present for care?

We ask to see your insurance card to ensure we have correct information with regards to billing your insurance. Should you present without your insurance card in hand, we will still see you for your illness. However, the visit will be charged as a Private Pay and you will be billed for the services until verification of coverage can be provided by you.

Can you just bill me for my co-pay?

No. We are required by the insurance companies to collect your office visit co-pay at the time of service. This is also the patient’s obligation in having medical coverage. We accept Cash, personal checks, Visa and MasterCard for your convenience.

I was in a motor vehicle accident. Why am I required to pay for my visit up front even if I have medical or vehicle insurance?

Bellevue Family Medicine is not contracted and has no collection recourse with third party payers. (Pemco, Allstate, State Farm etc) These companies may withhold payment until the accident claim is settled. Therefore, payment is required at the time of service and reimbursement from the third party payer is the responsibility of the patient.

I had a mole removed and my insurance company didn’t cover the procedure. Why didn’t my doctor tell me this was a non-covered service?

With all the insurance companies and plans available to patients, it is completely impossible for our office to be up to date on your coverage. It is your responsibility, as the patient, to educate yourself as to what benefits are available to you. We encourage you to read your benefits booklet and talk with your benefit coordinator.

I’m out of my medication. Who should I call for a refill?

We encourage you to be diligent about refilling medication. However, if your prescription bottle says “zero refills”, it is probably time for you to make an appointment. We ask that you call your pharmacy to request a refill and we suggest you do so at least 5 days prior to running out of medication. The Pharmacist will fax us a copy of the medication last dispensed to you which will provide the dosage and directions of your medication. This allows our nursing and provider staff to safely evaluate your needs and determine if we should see you in the office to further evaluate your treatment. If you have mail order service or require a hand written prescription, please notify our office 72 hours in advance.

I had an appointment last week and completely forgot about it. I just received a bill for a “No Show” fee. What is this?

Bellevue Family Medicine strictly enforces the NO SHOW policy. We ask that you cancel all appointments at least 24 hours in advance so that others suffering from illnesses can be seen. A $50.00 fee will be charged for all missed Physical and Surgery/Procedure appointments. A $25.00 fee will be charged for missed routine office visits.

What is a Nurse Practitioner?

A nurse practitioner is a registered nurse that has received specialized training in diagnosing and treating illnesses and providing health care maintenance. A Nurse Practitioner can prescribe medication, manage chronic medical conditions, order diagnostic testing, recognize complicated medical conditions that may require a referral, obtain health histories and perform physical exams, treat common illnesses and injuries, give advice on disease prevention and much more. The Nurse Practitioners work very closely with your physician to manage your healthcare and provide excellent medical attention to you.