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PPO Insurance and Housecalls

Why We Are Fee-For-Service

Most USA PPO insurance providers cover physician housecall services to some degree. Because of the nightmarish coding rules, complex paperwork, and frequently delayed payments to physicians by many insurers, we have opted to remain out-of-network for all USA-based companies. This allows us to keep fees lower, and to focus more on our patient’s care, rather than spend much of our efforts just trying to get paid for the care we have already provided.

Also, the fees allowed by insurers for in-network (contracted) providers cannot sustain an urgent house call practice of this nature, at least not here in the San Francisco Bay Area, where the cost of running a medical practice one of the highest in the nation. We therefore currently require payment for our services at the time of service for all patients who are insured with these providers.

How to Pre-Determine Your Insurance Reimbursement

To estimate your potential coverage for medical house call service you will need to know what remains unpaid of your annual out-of-network deductible. Essentially this deductible must be satisfied in order for reimbursement to occur. For example, some deductibles are perhaps $100 or $200, others may be $2000 or even $7000. After the deductible is met by the patient, most PPO insurers will reimburse up to 80% of house call medical costs. Some companies refuse to pay for after hours services or for physician excess travel. If limiting your financial outlay is your first priority when arranging medical care, we recommend that you contact your insurer directly to determine what is covered.

Insurance Claim Form Submission by Patients

We found, after offering to submit claims as a courtesy to our patients for a period of time, that the patients who submitted claims themselves were reimbursed more quickly. When we submitted the claims, the insurers tended to argue with us about coding not being done according to their individual company requirements. This delayed patient reimbursement significantly. Insurers are usually eager to argue about insignificant coding details with the medical practitioner. It is much different for the patient in most cases, since patients usually choose the insurer, thereby bringing value to the insurer. So when patients simply mail in their claim forms to the insurer, reimbursement tends to occur more quickly.

Insurance Reimbursement Strategies: What Patients Should Know

Most US PPO insurers want to keep your money as long as they possibly can. They are very savvy at doing this. So, which patients get greater reimbursement?, and who is reimbursed more quickly? The person who plays hard-ball once the insurer gives the first hint of being difficult tends to get more, faster. My patients who get their money fast tell me that they get on the phone and “give ’em hell!”. Being “nice” is worth a try at the start of the first call, but thereafter, this niceness can only work against you, according to many. Successfully reimbursed patients advise that if you call the claims office daily, or even twice daily, and talk to them like you mean business, you will get your money more quickly. Claims processors are banking on the “niceness” and politeness of most patients. So if your reimbursement is important for you, it may be worth trying this approach.

For company employees insured through their work, the human resources department may prove invaluable when it comes to getting reimbursed. Remember that the insurers always cater to the HR staff since these people hold the purse strings for large group policy purchases. So first be pleasant, then not so nice, then go to HR, if available, to get the job done.

Occasionally, patients report that reminding the claims person that they will seek treatment in the ER the next time that they are sick or injured, instead of utilizing a more cost effective housecall service, can be persuasive.

Health Savings Accounts and Flexible Spending Accounts

Patients with high insurance deductibles often qualify to place money in these tax-deferred accounts. A tax advantage occurs, while satisfying the annual deductible, when paying for medical services using these accounts. Medical house call services qualify as acceptable medical expenses when using these accounts. Your tax advisor can keep you up-to-date on these rules as they apply to your individual situation.