Medical Insurance Terms

Billed Amount – the full cost of an office visit or procedures performed at our office.

Allowed Amount – the amount your insurance company allows us to receive for the services we provide. Pricing is different per plan and is set by your insurance company.

Adjustment Amount – the difference between the full cost of our services and what an insurance company allows us to receive as payment; the ‘insurance discount’. As long as a claim is processed as in-network, the adjustment amount is written off, and is never passed on to the patient.

Date of Service – the date of your visit.

CPT® Code – Current Procedural Terminology (CPT®) code; codes created by the American Medical Association to describe the treatments or services provided to you by your doctor. These codes are standard across all insurance companies, and allow physicians to bill uniformly.

Diagnosis Code – Also known as the International Classification of Diseases (ICD-x) code, this was developed by the World Health Organization. American medicine is currently using the ICD-9 code set or the ninth version. These codes are used to identify and describe a patient’s illness or symptoms. These codes work in conjunction with CPT codes.

Explanation of Benefits –The EOB is a statement detailing how a claim was processed by your insurance company. It usually lists the CPT® codes, the diagnosis codes, the billed amount, the allowed amount, the adjustment amount, and any amount paid by insurance or responsibility given to the patient. The EOB also lists denied claims and gives reasons for denial.

Deductible – A set amount that must be paid by the patient before an insurance company will pay any expenses .

 

Frequently Asked Questions

We accept most insurance brands. However, we cannot guarantee that we are in-network with your particular plan even if we accept that brand of insurance. To make sure we are in-network with your plan, contact your insurance company and ask if we are an in-network provider for your plan.

Important Note: Since insurance benefits are unique to each patient’s insurance coverage, it is your responsibility to know your insurance benefits PRIOR to service being rendered. We are not responsible for unpaid amounts as a result of deductibles or denials from your insurance company. We can never guarantee insurance coverage for any service provided. You are responsible for charges denied by your insurance company.

We accept all insurance brands EXCEPT:

  • Medicare Advantage
  • Amerigroup
  • Care Improvement Plus
  • DaVita® Village Health
  • Integrated Health Plan
  • Medicaid
  • Peachcare®
  • Prime Health Services®
  • Today’s Options
  • Universal®
  • USA MCO® network
  • Veterans Administration (VA)
  • Wellcare®
  • Worker’s Comp

We are out-of-network with the following insurance companies. Please note, this is not necessarily a complete list. Please check with your insurance company.

  • Georgia 1st
  • Health Net
  • Humana® Preferred Open Access
  • Medcost®
  • Kaiser® (unless card says Multi-Choice and Multiplan)
  • Wellpath®
  • Medicare Advantage

Our new patients should fill out their information online on our Patient Portal! Please contact our office for an invitation. Click the link to take a look at our other important patient forms. Also, bring your driver’s license, insurance card, and co-payment.

New patients should arrive 20 minutes before your scheduled appointment. This is so we can ensure your patient portal is correct, and all identification and insurance cards are scanned and secure in your personal chart.

Yes, you need to bring your insurance card every visit. The Insurance Commissioner for the State of Georgia has asked that insurance cards be checked at each visit to protect against insurance fraud.

Your insurance company also requires us to check your card at each visit to confirm that we have the most current card and to protect against insurance fraud.

Plus, if you want to assure your insurance company pays, we need the most updated information for filing medical claims on your behalf.

If you are willing to pay out of pocket and file for your own reimbursement, you may leave your insurance card at home.

Fill out our medical records release form online and submit it online. Alternatively, you can print it on white paper and fill it out with BLACK ink, and then fax, mail or bring the form into the office.

Yes, our new patient visit generally costs $150. If you are an established patient with a focused problem, it could be less. This fee only includes the consultation with the doctor. If you have a procedure done, there is an additional charge. Payment is expected in full at the time your services are rendered. It is helpful to let your physician know you do not have health insurance.

No, we are a small business and unable to handle the overhead of financing our services.

We have 4 convenient locations in the Atlanta area. Get directions and more information.

If you have insurance, the cost of your visit is determined by your insurance company. Your insurance company tells us what they will ‘allow’ us to be paid for your visit (this is called the allowed amount). Of that allowed amount, the amount that you will have to pay depends on the specific details of your plan. Plans vary by company and by patient, so we are not able to give you an estimate of how much your visit will cost you. If you are concerned about cost, we advise you to come in for an office visit with one of our physicians. They can review your top concerns and determine which procedures are necessary (if any), and provide you with the codes that would be filed to your insurance company. You can then contact your insurance company; they should be able to provide you with a detailed description of your benefits based on those codes. If you want to get an estimate of common dermatology codes before your visit, call our billing office at 404-816-7900 x106.

There's a slight, but important, terminology distinction here.  “Covered” does not equal “paid”.  Your office visit may be a covered benefit, but that does not mean your insurance company is going to pay for the visit.  When calling your insurance company, be sure to specifically ask what you will have to pay, not what is covered. It is likely that at least some of the allowed amount will be applied to your deductible or coinsurance amounts.

The deductible is the amount that must be paid by the patient before an insurer will pay any expenses. As an example, assume your deductible is $500. If you come in to our office and your insurance company processes your claim and allows $150 for the services we provide you, but you have not met your deductible yet, they may give you the responsibility of paying that $150. Since deductibles renew annually, if you have 4 visits like this in a year, at the fourth visit you will have met your $500 deductible, and your insurance plan should pay the remaining $100 allowed.

Co-insurance refers to the percentage of the allowed amount that you are responsible for paying after the deductible is met. For example, a person with 80/20 coinsurance would be responsible for paying 20% of the allowed amount for their medical care after they have paid their deductible.

Full-pay patients (who do not have insurance) pay the retail rate for office visits and procedures. Even if you have a high deductible plan, meaning that you will most definitely have out of pocket expenses, it is wise to file to your insurance because in-network insurance plans usually provide patients with a greater discount than the retail rate. In addition, you will get credit with your insurance company for the money you pay for your healthcare.

There are many reasons why your insurance company may deny your visit, too many to mention here. What is most important to know about claim denial is that if we have sent you a statement, we have confirmed that the denial is not due to an error on our part. Before calling us to find out why your visit was denied, contact your insurance company and ask them. Oftentimes the insurance company needs information from the patient, and this will give them the opportunity to get the information they need to reprocess your claim. If your visit is denied for any reason, the full responsibility of the visit is yours.

Think of your insurance as a form of payment. If your credit card was denied at the supermarket, you would be responsible for contacting the credit card company to find out why, and then paying in cash for the goods at that time. At a medical office we are billing you after the services are provided, but they are still your full responsibility. Our relationship with your insurance company is based around the relationship that you established with them. Not only do you have a better chance at motivating them to action, but most times we do not have the information for which they are asking. We will file your claim to the insurance company that you provide, but we cannot pursue them for payment if they refuse to offer it. The best thing to do is to contact your insurance company, get the name of the person with whom you speak, a reference number for the conversation, and then call us with the information they give you. If we see you actively working with your insurance company to get a claim paid, we are willing to be patient in getting paid by them.

The codes that we submit to your insurance company are determined by our doctors to accurately describe the diagnoses and treatments from your visit. We often receive phone calls from patients stating that we filed the wrong code, and a patient’s insurance company told them to have us re-file. We cannot re-file your visit with different codes to get a different financial outcome, no matter what your insurance company tells you. Dermatological procedures are often considered to be surgeries by your insurance company, and dermatologists cannot file preventative codes. Unfortunately patients are not accurately told these things by their insurance companies when they call with questions about their visit. We have included this information in our financial policy as well, to make patients aware of this before their visit.

Patients without a copay will most likely have some responsibility after their visit due to a deductible or co-insurance. To keep collections costs down, which allows us to minimize our administrative costs for all of our patients, we ask that new patients without a copay pay a $68.25 deposit in estimate of that balance. That $68.25 will be applied to the cost of the visit and any amount left over will be refunded to the patient in the form of a check. After your first visit, you will not be asked to pay a $68.25 deposit again, it is only collected at your initial visit.