Insurance & Financial Considerations
Thanks for choosing SleepGR8 – The Institute of Sleep Medicine at Martin Clinic as an option to become your sleep medicine provider of choice. Although it is never fun to deal with the financial considerations of care, payment for services is ultimately the responsibility of each patient. We do, however, consider it our duty to work in partnership with you to help understand questions you may encounter.
Developing an understanding about your insurance status, or lack thereof, helps us to be of greater assistance to you. Healthcare has morphed into an incredibly complex system that doesn’t appear to be transparent from the outside looking in. One of our goals is to help you understand just what is involved in dealing with 3rd party payers. The following are some FAQs that patients generally want to know. We’ve tried to break things down to specific plans and styles of insurance coverage.
One thing you must keep in mind is that there are many links between your care and reimbursement for the same. Here’s a simple example of just how much work is involved in going from a patient visit to settling up for payment of services rendered. If any step is overlooked – we all must usually restart the process from the beginning.
How can I be certain I am being charged Usual and Customary fees?
We charge what we consider is usual, customary and reasonable. A patient is ultimately responsible for payment regardless of any insurance company’s arbitrary determination of another usual, customary and reasonable fee. We strive to provide excellence in patient safety, customer care and outcomes. Our hope is that you realize any and all financial expenses you incur will translate to “investments in yourself” that will pay dividends in terms of your overall health and well-being.
We feel that we remain competitive in our approach to costs incurred for testing, treatment and technology. We don’t advertise pricing online but will be happy to discuss these considerations via telephone or face-to-face in the clinic. In many cases, we are told of situations where costs have been double and sometimes triple our standard fees.
Always be aware of “site fees” that are routinely charged when sleep testing is conducted in typical or atypical hospital settings. These additional fees are no longer unique to hospitals. Many sleep labs are partnering with hospitals so their billing can be run through alternative avenues to reclaim a “site fee” that wouldn’t have been an option (or surcharge to you…) otherwise.
Occasionally someone calls to tell us that they found it could be done cheaper and faster elsewhere and we like to remind them that you generally get what you pay for so be cautious. The Latin phrase, Caveat emptor. It pretty much says it all – Buyer Beware!
Kind Capitalism is about corporations being fair and always striving to improve. In our mind, a GR8 company is more than just a GR8 product and a GR8 staff. And it’s bigger than just charging less and being better than the competitors. Kind Capitalism is about understanding the frustrations we all face, and striving to diminish these – one by one – day after day.
We realize this sounds a bit old school, and recognize that adopting Kind Capitalism in the torrent which is classic capitalism is difficult, at best. But the continuing profit-focused behavior of a majority of companies seems destined to lead to more inequality and more social despair. We agree that the solution is as simple as modifying corporate behavior – we just have to apply the principle of being “kind.” This new model, Kind Capitalism, allows capitalism to reward those that make our daily lives better, but does so in a way that is sustainable.
- Kind Capitalism means not taking every dollar a client is willing to pay, but enough to ensure the company can continue to grow and improve itself.
- Kind Capitalism means addressing customer issues in the same way – and at the same speed – with which you would want your issues addressed.
- Kind Capitalism means treating all clients equally.
- Kind Capitalism means also treating employees fairly, equally, and striving to improve their daily lives too.
For any business to do this is a balancing act, requiring constant vigilance and attentiveness to avoid falling into the easier and ubiquitous corporate mindset that all that matters is growth and profit – but Kind Capitalism does work, and SleepGR8 – The Institute of Sleep Medicine at Martin Clinic is corporate proof that this approach can be successful.
Does Private Insurance (non-HMO) cover sleep testing & treatment?
Yes, in most cases. Sure there are some policies that exclude patient benefits for sleep disorders but those are the exception. In our experience, we have only seen that less than about 3% of the patients we evaluate actually have insurance coverage that doesn’t pay for the treatment of sleep disturbances.
Fortunately, most insurers have heeded medical knowledge and accepted the notion that healthy sleepers live healthier lives and reduce their risks of other problems such as heart attacks, strokes and sudden cardiac death. For instance, treatment of sleep apnea alone can lead to improvement in heartburn & reflux, chronic allergies, chronic pain, chronic fatigue, and mood disorders (i.e. irritability, agitation, depression, anxiety and psychosis). Therefore, it makes sense to treat them! When a policy excludes sleep disorders, it generally relates to a decision made by an employer, and was selected because it reduced the cost of insurance premiums.
We will do everything within out power to help make you feel at ease about approaching the diagnosis and treatment of your sleep problems. We can help to obtain your benefits and information about any remaining deductible balances you may have and what your co-pays and co-insurance (if any) amounts will be. We will do this at no cost to you!
Even with that being the case, your insurance policy is a contract between you and that company and we aren’t a party to that contract. You will be provided an itemized statement or estimation of costs at the completion of your office visit so that you may file for reimbursement. We will automatically file for all of our services even if your insurance plan is not a plan in which we participate. You will likely be required to pay deductibles, co-insurance and co pays prior to scheduling any testing and before treatment can be initiated.
We encourage you to become familiar with your insurance plan and benefits prior to seeing us. Services are generally covered through most insurance policies. If your plan doesn’t cover a certain aspect of your care, you may be billed for full payment of the bill. To determine insurance coverage and personal obligations, call the customer service or member services department of your insurance company (the phone numbers are on your insurance card).
Always confirm your insurance company lists your medical providers as “participating providers.” If you are uncertain, let our staff know and hopefully we can clarify those concerns for you. If you seek care from out-of-network providers, you will most likely have a greater financial responsibility. Your insurance company can assist you in finding an in-network provider to limit the amount of money you will have to pay for your care.
We usually suggest patients work within the framework of their insurance plans to decrease out-of-pocket expenses. However, usually in the case of second opinions, an individual may determine that they will need to see an out-of-network provider to gain a better understanding of their problem and work towards achieving symptomatic relief.
How does Managed Care Insurance approach sleep testing?
Managed care insurance (primarily HMOs) generally prefer to have their members tested and treated in clinics that are within their own network of providers. For that reason, many patient’s with HMO style insurance are required to seek care from certain sleep clinics and/or hospitals. It is our opinion that most patients should initially seek treatment from providers that are within their insurance network. We remain able and interested to help patients with this style of policy: however, several things must be kept in mind. First, when you select an out-of-network provider, you are responsible for meeting higher deductibles in most cases. Second, you must also consider whether or not your insurance carrier will reimburse for treatment if it is prescribed from an out-of-network provider.
We file for all office visits and outpatient services with PPOs and HMOs in which we participate. Co pays are due at the time of service and you may be required to pay your deductible and/or co-insurance prior to being evaluated or undergoing testing. If you do not have your insurance card with you at the time of your visit, you will be expected to pay for your visit at the time of service.
Please remember, it is your responsibility to keep us informed changes in insurance status. If your insurance requires an authorization from your primary care physician prior to seeing one of our providers, it is your responsibility to obtain that authorization but we can assist you in doing so.
Does MEDICARE pay for sleep evaluation and treatment?
Yes, in nearly all cases. Medicare Part B involves payment for outpatient services and will reimburse for testing and treatment if it is proven to be clinically indicated. SleepGR8 – The Institute of Sleep Medicine at Martin Clinic participates in the Medicare program. In most cases where it is proven to be clinically indicated, Medicare will authorize testing and treatment for sleep disorders. We will file the claim with Medicare and will accept Medicare’s allowable payment. You will be billed for the 20% co-insurance and any deductible. If you have secondary insurance, we will file your secondary insurance for you after the Medicare payment has been received.
In most cases, when a patient has Medicare and a secondary insurance, the costs of both testing and treatment are totally reimbursed. If a patient doesn’t have a secondary insurance, they usually will have a cost of about $140 for testing and about $25 a month for treatment. Testing costs are dependent upon the number of tests performed [generally not more than 2 are required]. Treatment with CPAP is reimbursed by Medicare on a monthly basis for about 12 or 13 months until the equipment has been considered “paid” and it then becomes the real property of the patient. Medicare has decided to pay for treatment in this manner to prevent monetary losses in treating patients who refuse to use their equipment.
Although each patient generally has the right to choose their preferred Medicare provider, we always encourage patient’s to first discuss their interest in having a sleep study with their primary care physicians or sub-specialists. We like to make certain that physicians of record are updated on the status of their patients and the easiest way to maintain the proper communication of findings and treatment is to have your own physician or provider refer you for evaluation.
Do MEDICAID, SoonerCare & OEPIC pay for testing & treatment?
Yes, in most cases… SleepGR8 – The Institute of Sleep Medicine at Martin Clinic participates in the Medicaid, SoonerCare and OEPIC programs. We will file claims with these entities and accept their allowable payments. You will be billed for the any co-insurance, deductibles, and/or co pays that are applicable.
Recently, the Oklahoma Health Care Authority (OHCA) enacted a special rule that requires all sleep studies to be pre-authorized. If you are covered under their plan, prior approval for your testing must be obtained. There’s no guarantee whether or not testing will be approved or how long it may take for a determination to be reached. In our experience, the wait time is generally about 3 weeks.
What if I am Uninsured or Under-insured?
Just because you don’t have insurance doesn’t mean that you can’t afford high quality healthcare. This not only includes access to figuring out what may be wrong with you, but also what can be done to improve your life. Many patients are hesitant about exploring the possibilities of treatment when they don’t have insurance and that is understandable. However, at SleepGR8 – The Institute of Sleep Medicine at Martin Clinic we believe that pattern of thought is self-destructive.
Buying healthcare is still a lot like buying anything else in life – you tend to get what you pay for. The problem is, healthcare is tangled up with all of these contracts with “3rd party payers” – [the insurance companies] and it has diminished the consumer’s ability to understand the actual costs associated with both diagnosis and treatment. We are very thankful for the opportunity to participate in the care of our patients, whether they have insurance coverage or not. Should you have insurance that doesn’t cover “sleep benefits” then you probably feel uninsured, or at least under-insured. Bear in mind, dealing with insurance companies is still a hassle for healthcare providers and when we don’t have to deal with them we are usually able to negotiate discounted rates for accounts that are paid in-full at the time of service.
If you do not have insurance, your payment is due at the time of service unless prior arrangements have been made. We have worked diligently to establish diagnostic & therapeutic treatment options to accommodate every budget. If you or a loved one has been evaluated by our local Mayes County Free Clinic and are concerned that you may have a sleep disorder, make certain to discuss it with your physician. We work closely with the Free Clinic to provide sleep studies and treatment for those who qualify, at no cost to the patient. If you are in need of accommodations, please ask to speak with someone in our business office prior to seeing the doctor – especially if payment arrangements are necessary.
payment options/plans to promote getting care sooner than later?
Let’s face it, healthcare costs are rising as employees & employers are struggling with higher premiums, curtailed benefits, and an ever-present element of difficulty understanding policies. Please realize that if your insurance has not paid on your account within 45 days, you will be asked to pay for your services – even though your insurance is pending. We accept cash, check, Visa, MasterCard, and Discover Card.