Insurance Claims

While Dr. Denes and his staff work to keep their fees as low as possible, the ever-changing requirements of both private insurers and Medicare mean that in order to acheive the best financial outcome, it is necessary for patients to work actively with their doctors to make sure insurance claims are paid in a timely manner.

Many insurance companies now require second opinions before they will approve a surgical procedure. They often also require same day admissions and mandatory discharge dates. Despite our best efforts to comply with insurance company demands, we may not receive reimbursement for up to six months from the date of the claim. This presents problems not only for you, the patient, but also for us as we try to get paid for our services.

In addition to the extra requirements imposed upon us by insurers, operating costs and fees are also rising. We do everything we can to keep our fees reasonable in the face of rising costs for surgical supplies and services.

Reasonable and Customary Charges

Dr. Denes conducts diligent, ongoing research to ensure that his fees are fair. His staff monitors comparable local fees on a semi-annual basis, and they also compare Dr. Denes's fees to the most current Physician Fee Analyzer, which is compiled and published by Medicode, a division of Med-Index. The resulting report is customized by Dr. Denes with the current American Medical Association coding, and tied to both geographic
and zip code demographics. Dr. Denes keeps his fees mid range relative to this extensive data base. This is how we arrive at our "reasonable and customary" charges.

Insurance companies begin their calculations of "reasonable and customary" charges by using the 50th percentile, or the fee charged 50 percent of the time in a given area at a given time. This may seem like it would produce a fairly consistent figure, but if you checked the reimbursement amount for the same surgical procedure at several insurance companies on the same day,you would probably be given different "reasonable and customary" chargesfrom each one, because each company may be working from different data gathered at different times from different locations.

It is important to remember that Dr. Denes's surgical services are provided dependent upon a contract between you, our patient, or your family member who has been designated to act on your behalf. He does not have a contract with your insurance company, but with you. Whenever possible, patients are informed of Dr. Denes's expected fees prior to surgery, alongwith an estimate of what portion your insurance company will pay. You will be asked to pay the difference prior to undergoing surgery.

Occasionally, insurance companies will pay less than our estimate because their calculation of "reasonable and customary" charges for the procedure varies from ours. In those instances, the patient will be billed for the balance that their insurance company will not pay.

Our office does sometimes make allowances for demonstrated hardship cases. If you feel your circumstances warrant such consideration, please discuss this with our office manager before your surgery is scheduled.

If you have a secondary insurer, we will file those forms as long as we are made aware of the secondary at the time of your enrollment. If you do not inform us of youre secondary insurer, there will be a fee of $5.00 per form to complete any additional forms you would like to file. EXCEPTION: By law, we provide all necessary insurance claim forms for Worker's Compensation patients.

Any insurance forms you ask us to fill out may be picked up two working days after we receive them. Or we will mail them if you provide us with a self-addressed, stamped envelope.
Group and Individual Insurance Claims

1. As a courtesy to our patients, we file claims with your insurance company for reimbursement of your surgical fees. However, it is important to remember the contract is between you and your insurer. As a patient making an insurance claim, you have certain obligations.

For Group Insurance Policies, you must fill out an employee statement, usually available from your employer's Human Resources department.

For Individual Insurance Policies, you must fill out a claimant's statement. This form may be obtained from your insurance company or agent.

Claims not accompanied by these forms cannot be processed for payment.

We do not accept assignment on individual insurance policies; however, we will provide you with an unassigned claim you may present to your insurance company to get reimbursement for your expenses.

2. We will verify your benefits and deductibles with your insurance carrier by telephone. On the standard 80%-20% policy, your 20%, along with any unmet portion of your deductible, will be due prior to your surgery. As a convenience to our patients, we accept Visa, Mastercard, and American Express credit cards.

3. After your insurance company has paid your claim, any credit balances resulting will be refunded directly to you.

4. We will allow 90 days for your insurance company to pay your claim. We believe three months is more than adequate time for insurers to pay your claim, and for us to carry the account on our books. If your insurance company has not paid your claim within the allotted 90 days, the full amount of your bill will be due from you.

It is to your advantage to follow up on your claim with your insurance company. We send periodic statements to keep you apprised of the status of your account with us, so you can know if your claim has been paid and take steps to expedite payment with your insurer if the account is still open.