Insurance & Billing FAQ
All of these terms indicate that our healthcare professionals agree to provide medical care under terms of a contract with a particular insurance company. This means we are obligated to provide discounts allowed by your policy. Once these discounts are in place, your insurance company may pay all, part, or none of the remaining balance. Contact your insurance plan by calling the number on the back of your insurance card to verify if we are a participating provider for your policy's network.
The easiest way to confirm you've received all the discounts allowed is to review the explanation of benefits (EOB) provided by your insurance company. Most will have the patient balance calculated for you. Just match the balance for the dates of service with the balance you received from OrthoWest. Those amounts should match. If they do not, please call our billing department at 402-637-0809, and we'll be happy to review your account.
Our most common insurance companies are Blue Cross, Medicare, United Healthcare, Midlands Choice, Coventry, Aetna, Principal, and Cigna.
Some insurance companies have policies that are not part of their main network. For example, we are part of BlueCross BlueShield's PPO Network; however, BCBS has policies that are outside their PPO Network. Sometimes your card may indicate if you are within that company's major network, and sometimes not. The only way to know for certain is to call the number on the back of your insurance card.
We provide the discounts allowed by your policy. Once these discounts are applied, your insurance company may pay all, part, or none of the remaining balance. Your explanation of benefits (EOB) will explain which part of the balance you owe, and should differentiate between copays, deductibles, and coinsurance.
If your insurance states that you owe a balance different from our balance, call us at 402-637-0809 and we'll review your account.
Normally a patient will receive three bills: one bill from the physician (OrthoWest), one from the hospital, and one from the anesthesiologist.
Physicians and anesthesiologists provide services within a hospital, but are not employees; they are independent and so provide separate billing. Physician can be credentialed and provide services at several hospitals.
Think of this system like your house. Had you never lived in a house, you might expect that you would have to pay one "house" bill that covers every service. However, homeowners have to pay mortgage, gas, electricity, phone, and other bills separately, because these are services provided by different companies to the same location.
Our bills look like this on the upper left side:
Surgical treatments of any kind are expensive. We suggest that you anticipate meeting your deductible. We ask patients for half of their current unmet deductible.
Most policies have a coinsurance (a percentage of the contracted charge). If you request an estimate, you'll receive a total based on OrthoWest's charges only; however, the final amount is determined by your insurance policy. It's most accurate to ask for the CPT codes that will be billed and provide those to your insurance company to estimate the coinsurance and deductibles based on your policy.
You should be familiar with charges on your bill; however, sometimes the terminology used in medical billing can be confusing. If you are unsure about any charge you have been billed for, feel free to call us.
OrthoWest doesn't send bills to patients until their insurance has processed the claim. If you haven't received any correspondence within 30 days, then your insurance may have paid your balance in full, or they are taking a very long time to process your claims.
A copay is a fixed dollar amount set by your insurance contract that is required to be paid at the time of an office visit. This amount is normally between $15 and $50, and is usually listed on your insurance card. OrthoWest requires that the copay to be paid at the time of service.
A deductible is an annual dollar amount established by your insurance plan that is deducted from insurance benefits. This amount is your obligation and we require half of the current unmet deductible to be paid prior to having surgery.
Coinsurance is a percent set by your insurance plan that is deducted from insurance benefits, generally after your deductible is met. This percent usually ranges between 10% and 30% and is your obligation to pay.
A patient who does not have any valid health insurance is a "self-pay" at OrthoWest. You will be asked to pay $170 before you will be seen for your first visit, and $115 for subsequent visits. This covers the doctor's office visit charge and does not include x-rays or other related services. We will send a bill for those charges. Initial self-pay consult visits are charged $231.
OrthoWest does not bill third party insurance. OrthoWest may bill your motor vehicle insurance, but will not bill someone else's. You will be asked for your personal health insurance if your MVA coverage is depleted. However, if your primary insurance is BCBS of NE, we are contracted to submit bills to them for all MVA claims.
OrthoWest does not bill third party claims directly, and, if documented and processed properly, most insurances will not cover accident claims; therefore, your account will be considered a "self-pay" account and you'll be required to pay the initial $170 office visit, as well as any other charges for services provided to you. Often, if the other insurance is in agreement to cover charges, then all you have to do is give them a copy of your bill sent by OrthoWest, and they will reimburse you.
OrthoWest requires that workers' compensation claims be authorized by your employer's workers' compensation carrier prior to your visit. It is our internal policy to speak directly to the workers' compensation insurance company for this authorization prior to having an appointment scheduled.
If not authorized, we will require a $170 payment, or you may reschedule after your claim is authorized. Get more information about Workers' Compensation claims.
Yes, the reason for the balance supplied by the insurance company is listed on your statement below the procedure description. Here is an example:
Charges pending insurance are not calculated as part of the "Patient Due" charges. Those charges are listed as "Ins Pending." Also, specific charges that are pending insurance will have a star in the "INS" column.
Often supplemental insurances will request CPT, diagnosis codes, and/or the original charge. This information is supplied on your OrthoWest statement.
Yes, we have an online portal that accepts Visa, Mastercard, and Discover. If you sign up for online statements, you can pay while viewing your statement.
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