2. To what services does your deductible apply?
Your deductible may not apply to all services. Frequently, the deductible does not apply to preventive services. For example, let's say you had a screening mammogram and the charge was $120. As in the last example, assume you have a $100 deductible. Your insurance company may say the "deductible does NOT apply" to a mammogram. Therefore, your insurance would start to cover its share of the entire $120....or better yet, your insurance company may pay for the mammogram in its entirety and you would owe nothing. Alternatively, your insurance may simply not cover screening mammogram in which case you would be responsible for the entire bill AND no portion of this out of pocket payment would go towards reducing the amount you owe towards your deductible. Check with your insurance company if you are not sure which services apply to your deductible.

3. What is a "co-pay"?
Most health insurance companies use a co-pay to place some restraint on the utilization of health care services. A co-pay may be a specific dollar amount (for example, a $5 co-pay) or a percentage of the charge (for example, a 20% co-pay). Different health insurance companies have different co-pays. You should know your co-pay. Referring back to the original example, let's assume you have a 20 percent co-pay. Again, the charge for your office visit was $120 and you had a $100 deductible. Assume that the deductible applies to the services under consideration. You pay the first $100 AND 20% of the remaining $20 (the "co-pay" or 20% of $20 is $4). Therefore, in this scenario, you would pay $104 out of your own pocket and the insurance company would pay $16. If your health insurance has a specific co-pay (for example, $5), we ask that you pay this amount at the time of your visit. You can pay this amount in the business office located in the lower level of the building or at the patient registration desk on the main floor.

4. Do you need a "referral"?
Some health insurance planshave a panel of physicians who will provide care for the patients within a particular health plan. If you want to see a physician outside of this panel, you will probably be required to get a referral. You should have received a book from your insurance company that lists which physicians participate in your health plan. If the physician you want to see is NOT listed in the book of participating physicians, you probably need to get a referral to see this physician. DO NOT ASSUME THE PHYSICIAN THAT WE REFER YOU TO IS A PARTICIPANT IN YOUR HEALTH PLAN. We deal with many different health plans so it is difficult to keep track of all the participating physicians. It is your responsibility to know when you have been referred to a physician outside of your health plan and when you need a referral. We will help you get the necessary referrals. Sometimes your health plan will not allow you to see the physician you choose. That is, the insurance company may not honor your request for a referral. You still have the option of seeing any physician you please but your insurance company may not pay any portion if the physician you choose is not a participating physician in your health plan.

5. Preventive exam ("Annual" physical):
Some health insurance plans pay only if you have a medical problem. Other health insurance plans pay a certain way if you go to the doctor for medical problems and a different way if you see the doctor for preventive services. It is not always easy to define a visit to the doctor as purely "preventive" or purely due to an ongoing medical condition. If your health insurance plan pays for preventive services (for example, an annual physical exam, screening cholesterol, mammogram, flexible sigmoidoscopy for screening for colon cancer, etc.), please tell your physician or his/her nurse. If you do not know whether your health insurance plan covers these services, please inquire directly with your health insurance company prior to receiving these services. You will be billed for preventive services if your insurance does not cover preventive services.

6. Prior authorization/ pre-certification:
Many health insurance plans require pre-approval for certain procedures (for example, CAT scan of head, upper endoscopy to look at the stomach, a visit to the emergency room or convenient care center at a hospital) and/or pre-certification if you need to be admitted to the hospital. Please tell your physician or his/her nurse if your health insurance plan has these requirements.

7. Medical necessity
Many health insurance plans use the term "medically necessary". They claim to only pay for "medically necessary" health care. Let me assure you that we practice high quality health care at Dubuque Internal Medicine. The problem arises when the health insurance company and your doctor have different definitions of "medical necessity". This issue is most obvious in the realm of prevention. Your doctor may order a PSA to screen for prostate cancer. If you have no signs or symptoms of prostate cancer but simply have a family history of prostate cancer, your insurance company may view this test as NOT medically necessary even though your doctor thinks it is a good idea. If your insurance company denies payment because they determine a test as "not medically necessary," you are still responsible for payment.

8. Who files the insurance?
If you have Medicare, Wellmark traditional Blues, Alliance Select, SISCO Advantage or John Deere Health Plan, we are required to file any encounter with your insurance. In all other situations, it is your (the patient's) responsibility to file your insurance claim. As a courtesy, Dubuque Internal Medicine files your claim for up to two different insurance companies. If you have more than two health insurance plans, you will need to file the claims for any company beyond the first two.

9.What is covered by my health insurance?
The business office at Dubuque Internal Medicine deals with well over 50 different health insurance plans. There is no way that we can know which services are covered by your particular plan. It is your responsibility to contact your insurance company to obtain this information. If we do know how your plan pays for a particular service, we will certainly share this information with you.

10. Any changes?
If there has been any change in your health insurance coverage since your last visit to Dubuque Internal Medicine, please report these changes to "PATIENT REGISTRATION." These changes may include any name change, address change or change in the insurance company. Also, if your normal insurance plan is NOT to be billed for the services rendered on the day you are being seen, please tell "PATIENT REGISTRATION" every time you return for such a visit. For example, let's say you are injured at work and you present to Dubuque Internal Medicine for medical care. This visit will probably be considered a worker's compensation claim. If you do not report this information to patient registration, the bill will be submitted improperly to your personal health insurance. Bring in your most recent insurance card to each visit.