We understand the importance of making well-informed and confident decisions when selecting your health care provider(s). The decision to undergo care is an important one and there is a wide range of factors that you should consider before making your decision including, but not limited to, financial decisions. Certain financial decisions you make may affect your overall health care costs. 

You may avoid unexpected health care costs by knowing your health insurance eligibility and benefits prior to selecting your health care provider(s). Our dedicated Patient Financial Services Department will assist you with verifying your health insurance plan eligibility and benefits including but not limited to your copayment, deductible and/or coinsurance prior to scheduling your in-person and/or telehealth visit. You can reach the Patient Financial Services Department by calling 888-990-0077. 

1. Accepted Health Insurance Plans 

   We are a participating provider of a growing number of health insurance plans. You can find the full list of the health insurance plans in which we participate at www.orthopedicinstitute.com/insurance.  
    
   Health insurance plan eligibility and benefits are often difficult to understand; therefore, it is important to check with our dedicated Patient Financial Services Department whether we participate in the specific health insurance plan(s) by which you are covered. You can reach the Patient Financial Services Department by calling 888-990-0077. 

2. Medicare 

   Our services are partially covered by Medicare. We will file a claim with Medicare for our services in two separate portions: professional services and facility services. The professional services performed by Orthopedic Institute’s doctors and its licensed medical professionals will be billed to Medicare. Generally, Medicare will cover eighty percent (80%) of the current professional fee schedule for the professional services, and the patient is responsible for the remaining twenty percent (20%) of the current professional fee schedule for the professional services. If the patient has a Medicare supplement or secondary insurance plan, we will file a claim with the Medicare supplement or secondary insurance plan for the remaining twenty percent (20%) of the current professional fee schedule for the professional services. 

   Our accredited ambulatory surgery centers are not enrolled or contracted with Medicare. We are not permitted to file a claim with Medicare for the facility services. You may request to have your Orthopedic Institute surgeon perform your procedure and/or surgery at an alternative facility that is enrolled and contracted with Medicare.* To learn more about your specific health insurance plan eligibility and benefits, call our dedicated Patient Financial Services Department by calling 888-990-0077. 

3. Secondary Insurance 

   We are a participating provider of a growing number of health insurance plans. You can find the full list of the health insurance plans in which we participate at www.orthopedicinstitute.com/insurance. How secondary insurance works: Once your claims have been processed through the primary health insurance plan, the remaining balance will be processed through your secondary health insurance plan, with the remaining payments received applied to the remaining balance. 

4. Copayment, Deductible and Coinsurance 

We will collect your copayment, deductible and/or coinsurance, as applicable, at the time of service. 

There are a variety of federal and state laws that govern our interactions with federal healthcare program beneficiaries. The Center for Medicare and Medicaid Services (“CMS”) is the federal government agency responsible for overseeing Medicare and Medicaid Services. CMS has mandated that all physicians, facilities, and any and all other health care providers must collect the copayment, coinsurance, and/or deductible, as applicable, for each patient encounter.  The Office of the Inspector General (“OIG”) is responsible for enforcing CMS’ mandate.  

Physicians, facilities, and any and all other health care providers that do not collect the copayment, coinsurance, and/or deductible, as applicable, are subject to civil and criminal prosecution for fraudulent billing under federal and state law. In addition to the foregoing, private insurance carriers may prosecute and/or bring civil complaints against physicians, facilities, and any and all other healthcare providers who fail to collect the patient’s copayment, coinsurance, and/or deductible, as applicable, at the time the services are rendered. 

5. Out-of-Network 

We are a participating provider of a growing number of health insurance plans. You can find the full list of the health insurance plans in which we participate at www.orthopedicinstitute.com/insurance. We are not, however, contracted with every health insurance plan. Being out-of-network with certain health insurance plans does not mean our professional and/or facility services are not covered by most health insurance plans; rather it means that the professional and/or facility services are not covered at contracted rates with certain non-contracted health insurance plans. Knowing the difference between in-network and out-of-network care can help you save on health care expenses. 

6. What’s the difference between In-Network and Out-of-Network? 

Most health insurance plans provide their members with access to a network of doctors, facilities, and ancillary health care service providers who agree to accept discounted (or contracted) rates to participate in the health insurance plans network. These providers, facilities, and ancillary health care service providers are known as either “contracted” or “in-network” health care providers.  

The health care providers, facilities, and ancillary health care service providers that do not accept discounted (or contracted) rates and do not participate in the health insurance plans networks are known as “non-contracted” or “out-of-network” health care providers. 

6. Prior Authorization 

Certain health insurance plans require prior authorization for you to see medical specialists (e.g., orthopedic surgeons, physiatrists, podiatrists). Our dedicated Patient Financial Services Department will attempt to complete the prior authorization process on your behalf. Prior to your scheduled appointment, you will be notified by our dedicated Patient Financial Serviced Department if we are unable to obtain prior authorization for your visit. 

7. Pre-Certification 

Certain health insurance plans require pre-certification prior to you visit. Our dedicated Patient Financial Services Department will attempt to complete the prior authorization process on your behalf. Prior to your scheduled appointment, you will be notified by your dedicated Patient Access Coordinator if we are unable to obtain pre-certification for your visit. 

 

*Not all Orthopedic Institute surgeons hold active medical staff privileges at alternative facilities.