A Message from Dr. Wittig
As you embark on your journey to treatment, please remember that your right to obtain the best and most appropriate form of medical care should not be limited by your health insurance coverage.
As a cancer physician for 15+ years, I am dedicated to providing all my patients with the highest level of care. This means providing appropriate medical resources and the best treatments regardless of insurance status in order to achieve the very best level of care possible. Although this philosophy of practicing medicine often conflicts with for-profit health insurance companies, which has necessitated the limitation of my participation with many carriers, this should not be of concern to you.
Therefore, please remember while making your selection of physician and treatment plan that my staff and I can and will work with any health insurance company with whom I do not currently participate. Together, we will work with your carrier to minimize your out-of-pocket expenses so that your financial needs can be protected without compromising your medical needs.
If you have any questions, or would like to discuss your personal healthcare coverage plan further, please do not hesitate to contact our office so that we can guide you.
James C. Wittig, MD
Q & A
What does 'usual, customary and reasonable' mean?
Each insurance carrier has an established payment rate for each test, procedure, or other medical service depending on the provider's geographical area. The insurer arbitrarily decides what is appropriate, approved or allowed. Unfortunately, the insurer's determination may not reflect our current costs to provide a quality service to you. This rate can be called either usual, customary, and reasonable (UCR), or reasonable and customary. Each insurance company differs from each other in what they consider customary and reasonable. Dr. Wittig's charges may be different from what an insurance carrier decides is customary and reasonable. Patients are responsible for paying any difference between our charges and the carrier's payments. This is referred to as balance billing. In many instances, Dr. Wittig's office is capable of negotiating an acceptable rate of reimbursement to minimize and sometimes negate the amount that is balance-billed to the patient.
Most insurance companies require Pre-Authorization for a patient to undergo radiological studies, biopsies and/or surgical procedures. In addition, your insurance plan (usually an HMO) may require a Referral from your primary care physician (PCP) to undergo the study, test, biopsy and/or surgery. This referral is in addition to the Pre-Authorization. With most insurance providers, the authorization process can take up to 72 hours, and in some cases up to one week. Because of the uncertain turn-around time to obtain a Pre-Authorization, it is not possible to schedule radiological studies or surgeries until the Pre-Authorization has been obtained. If a Pre-Authorization is denied, additional time will be needed to appeal the denial. Our office appreciates your patience during this process, and will submit all the required paperwork for an authorization within one day of your visit. Our staff will work diligently to obtain the Pre-Authorization from your insurance provider as quickly as possible. It is the patient's responsibility, however to obtain the referral.
In instances where Pre-Authorization is delayed by the insurance company, it is often beneficial if the patient ( who is also the Consumer ) calls the insurance company directly to discuss the Pre-Authorization with the insurance company's representative. From our considerable experience with insurance providers, we have found that when the patient/insurance company client is involved, the process is expedited significantly.
We request that all patients contact their insurance provider in advance to determine if a Referral in addition to a Pre-Authorization is required. If so, you will need to obtain the Referral from your primary care physician and bring this Referral with you at the time you undergo the test, appointment, biopsy, procedure and/or surgery.
A Referral is a document usually obtained from your primary care physician (PCP) which gives permission for you to undergo a specific procedure, radiological test or be seen in another physician's office (usually a specialist) for a consultation. It is the Patient's responsibility to obtain all necessary Referrals from their primary care physician (PCP) and/or insurance companies for any office appointments, radiological tests, biopsies, surgeries and/or other procedures.
Office Appointments: All Referrals for office appointments and consultations should specify that the appointment include X-rays. If this is your first appointment, the Referral should include a biopsy, as well as an X-ray.
Failure to obtain/provide appropriate Referrals: All bills or insurance claims incurred by a Patient that are not paid by their insurance carrier due to the Patient's failure to provide an appropriate Referral Form will become the financial responsibility of the Patient. After payment is received by the office, a receipt will be provided to the Patient, which may be submitted to the insurance carrier to attempt reimbursement.
Important Points to Remember
- In order for us to negotiate with your insurance company, you will first need to become a patient of Dr Wittig's. This may require payment for your first office visit and possibly a few additional office visits prior to surgery. It is important for you to know if you belong to an HMO, PPO or Traditional Indemnity Insurance plan and your deductible.
- If you require surgery, we are willing to negotiate rates with your insurance company on an individual basis. Our goal is to provide you with the best care and to make your insurance company pay for your entire care!! Although it may not be possible in all cases, we are usually capable of negotiating acceptable rates and minimizing your out-of-pocket expenses, once your deductible is met.
- If you belong to an HMO or do not have out-of-plan benefits, please remember that your HMO and Primary Care Physician are obliged to provide you with a referral specifically to another orthopedic oncologist if they will not approve you seeing Dr. Wittig or if the HMO will not negotiate acceptable rates with Dr. Wittig. Please note that Orthopaedic Oncology is an extremely unique sub-specialty. There are only approximately 100-150 Orthopedic Oncologists in the United States. The majority of Orthopedic Oncologists in the United States do not contract (participate) with insurance plans because they have found difficulty providing patients with the complex care that they require with the low rates of reimbursement when contracted with medical insurance companies, especially HMOs.
- Remember, as the patient, you are the customer of the insurance company. Insurance companies respond best to demands and approvals when the patient advocates for themselves!! We agree that this may be difficult and stressful as it may require frustrating phone calls during a tough period of time. We will assist you and discuss everything with you and your insurance company. Better results are seen however, when the patient makes phone calls and demands either a case manager or a point person to help with their total care. You can usually find them online or by calling your insurance companies customer service department.
- Consider looking into a Health Savings Account (HSA) or Medical Savings Account (MSA) at work. These are tax-deferred savings plans, like an IRA, that allows one to set aside a certain amount of money to pay for medical expenses up to a certain amount. An overlying or umbrella insurance policy (either indemnity or PPO) then covers expenses after a deductible is met.
- If you encounter difficulty scheduling an initial consultation with me because of insurance issues, please contact one of my secretaries, at 551-996-2533 or send an email to me at DrJamesWittig@gmail.com.
Glossary of Insurance Plans
HMO (Health Maintenance Organization) - There are many different types, and they are the most complex to understand. Generally speaking, health care expenses are only covered by an HMO if a patient goes to a provider (doctor or specialist) within their organization (network). HMOs may or may not require the selection of a primary care physician, who will then coordinate a patient's care. Seeing a specialist generally requires a primary care physicians approval, and the HMO must grant approval before a hospital stay (unless in the case of an emergency). HMO is the least expensive to the consumer to purchase of all the managed care plans, but an HMO has more restrictions and takes more has total control of your medical care.
PPO (Preferred Provider Organization) - Typically more flexible than an HMO, they are usually more expensive to purchase. Patients can see any physician or specialist they want with the understanding that co-payments, co-insurance and/or deductibles will be higher.
POS (Point of Service) - A combination of both an HMO and PPO whereby a patient can see a physician within the plan and pay a small co-payment. If a physician is seen out of the plan (out-of-network) patients are expected to pay a percentage of a remaining charge after a deductible has been met.
Traditional Indemnity Insurance - These plans are the traditional form of health insurance. No restrictions are placed on physicians or hospitals or providers. Although, the most expensive of plans it allows the most freedom to choose the physicians and specialists (provider) you want and then be reimbursed for a percentage of the charge once the deductible has been met.
*Keep in mind that no matter what type of managed care plan you have chosen, you are ultimately pre-paying for care that you may or may not need but when that need does arise you have the right to fight for your interests and seek the best care possible.
Interesting resources/articles on insurance:
Top-paid health care bosses
Wednesday, March 12, 2008
http://www.bostonherald.com | Local Coverage
Andrew Cuomo takes on Insurers
February 28, 2008
OPINION | February 18, 2008
Editorial: A Rip-Off by Health Insurers?