Frequently Asked Questions

 

Billing & Insurance

IF I HAVE A QUESTION ABOUT MY BILL OR HOW MUCH MY PROCEDURE WILL BE, WHO SHOULD I TALK TO?

Please call the MedBridge Patient Services Department at 855-633-2743 M-F 8am-5pm. This is a toll-free number, so it won’t cost you anything to call.

HOW DO YOU DETERMINE PATIENT PORTION COSTS?

Peninsula Procedure Center is contracted with several insurance companies. These contracts specify how much money your insurance will allow as payable for a procedure. MedBridge will assess the insurance contract and your plan benefits to estimate your patient portion. Once your in-network insurance processes our claim, we will bill per the terms of the explanation of benefits according to your plan benefits, incorporating any payment made on your date of service. If your insurance is out-of-network at our facility, we will do our best to set your patient portion based on your in-network benefits.

WHEN WILL I BE EXPECTED TO PAY THE AMOUNT THAT IS MY RESPONSIBILITY?

You are expected to pay at least part of your patient portion on the date of surgery. If you will not be able to make the payment at that time, please contact MedBridge at 855-633-2743 BEFORE the date of your surgery to discuss your options and to set up a payment plan.

WHY AM I ASKED TO PAY ON THE DAY OF SERVICE?

In keeping with the terms of your agreement with your insurance company, as well as the agreement between the insurance company and Peninsula Procedure Center, it is our practice to request that you pay at least part of the facility fee on the date of service.

MedBridge does their best to provide you with an estimated facility fee before you receive services. This gives you the opportunity to understand how your health insurance will be applied to the services you receive at Summit. Feel free to ask MedBridge specific questions about your insurance benefits as well as payment plan options.

WHAT IS A “CO-PAYMENT”?

A co-payment (often called “co-pay”) is a set fee that the insured person pays to providers at the time of service. Co-pays are applied to emergency room visits, hospital admissions, outpatient surgeries, office visits, etc.

WHAT IS A “DEDUCTIBLE”?

Deductibles are provisions that require the insured person to pay a specified amount before insurance benefits are provided. For example, if your policy has a $500 deductible, you must accumulate and pay $500 out-of-pocket before your insurance will begin paying a percentage of service charges. Once you have accumulated and paid your $500 deductible to your medical providers, your insurance plan will start paying a percentage of future medical bills. You are thereafter responsible for your coinsurance. Deductibles typically re-set annually.

WHAT IS “CO-INSURANCE”?

Co-insurance is a form of cost sharing. After your deductible has been met, your insurance plan will begin paying a percentage of your bill. After your insurance has processed the claim and paid the percentage determined by your plan benefits, you will owe the remaining percentage, or “co-insurance.”

WHAT DO THE TERMS “IN-NETWORK” AND “OUT-OF-NETWORK” MEAN?

If you have selected a PPO plan, you will have both in- and out-of-network coverage. Healthcare providers that participate in your health plan are often referred to as “in-network,” and providers that do NOT participate in your health plan may be referred to as “out-of-network.” If Peninsula Procedure Center is out-of-network, we will check both your in- and out-of-network benefits and do our best to offer a facility fee that is comparable to an in-network provider.

WILL SUMMIT SURGERY CENTER SUBMIT CLAIMS TO MY PRIMARY AND SECONDARY INSURANCE?

As a courtesy to our patients, we submit claims to your primary and secondary insurance companies. We will do everything we can to advance your claim, and will contact you if we need your involvement in the process.

WHAT IS AN “EXPLANATION OF BENEFITS” (EOB)?

An EOB, or Explanation of Benefits, is a letter from your insurance company that provides information about how insurance processed your claim. If you have any questions about your EOB, please call MedBridge.

WHAT SHOULD I DO IF THE INSURANCE COMPANY SENDS PAYMENT DIRECTLY TO ME?

If you receive a check from your insurance company, please immediately call MedBridge at 855-MEDBRIDGE. We will ask you to endorse the check to Peninsula Procedure Center and send it directly to our office. It is very important that you endorse this check immediately to Peninsula Procedure Center: it is money due to the facility and is not to be used for any other purpose.

HOW AND WHERE CAN I PAY MY BILL? WHAT FORMS OF PAYMENT ARE ACCEPTED?

You can pay:

  • By telephone with a credit or debit card by calling MedBridge at (855)-MEDBRIDGE

  • By mail by sending your billing statement and payment (by check, credit or debit card) to Peninsula Procedure Center, 369 Main Street, Suite 100, Redwood City, California 94063

  • In person at our center (by cash, check, credit or debit card)

DO YOU BALANCE BILL out-of-network insurance?

No. Our practice does not balance bill. If insurance does not pay the fully-billed amount, we will not bill you for the difference. You will owe the amount that is discussed with you prior to surgery. Learn more about the No Surprises Act below.

Out-of-Network Policy

Our policy regarding billing patients for “out-of-network” surgeries is based on two central principles:

  • Providing certainty to the patient, and

  • Ensuring collection by the surgery center.

Your insurance carrier might refer to our surgery center as an “out-of-network” facility. This does not mean that we do not accept your insurance, but it does mean we do not currently have a contract with your particular health insurer. However, if you have an insurance policy with out-of-network benefits (e.g., a PPO policy), you have the additional benefit of visiting physicians and surgical facilities that are outside of your insurance carrier’s network, such as our surgery center.

We choose to stay out-of-network with certain insurance companies to maintain flexibility in optimizing your treatment. By staying out-of-network, we can tailor our processes to suit our surgeons, the surgeries performed here, and, most importantly, our patients. We are pleased to enter into contracts with insurance companies if it is in the best interests of the surgery center’s patients and medical staff.   Of course, contracted rates need to match or exceed our competition’s pricing in the marketplace.  (We generally consider our competition to be the local hospital outpatient departments.)

Our surgery center may choose to remain out-of-network with a specific insurance company because the insurance company cannot or will not offer contracted rates that compare well with those of our competitors. However, we do not want our patients to be financially harmed by our status as an out-of-network provider. For that reason, in determining what to charge a patient who has out-of-network insurance, we try to adjust the patient’s portion of the payment to compare to what the patient might pay in-network. We are able to provide these discounts because we collect at least 50% of the payment on or before the date of service. This comes at a risk to us, since we agree to perform the services without knowing what the insurance company will ultimately pay us.

So, if you are a patient with out-of-network insurance benefits, in most circumstances* we can offer you the following at our surgery center:

  • The certainty of knowing, before your surgery, what you will pay;

  • A discounted cost to you that is reasonably based upon your in-network benefits – so long as you pay at least 50% of that amount on or before your surgery date; and

  • The assurance that if you pay 100% on your surgery date, you will never receive another bill from us.

This policy is based upon both our concern for patients’ best interests and our need to make sound business decisions. First, we consider our relationships with our patients to be the highest priority. We endeavor to give our patients assurances about the amount they will owe when they come for service at our surgery centers.  Navigating the insurance process is daunting and confusing, and we are committed to helping our patients avoid the stress of these unknowns.

Additionally, we understand that when patients are billed for medical care after they receive service, they are 50% less likely to pay their responsibility.   Therefore, we offer incentives for the patient to pay before, or on, the date the patient receives service, which increases the likelihood of receiving payment and reduces the overall cost of health care by eliminating the need for collections and follow-up with the patient.

We are happy to answer any questions you may have. Please call the MedBridge Patient Services Department at 855-633-2743 M-F 8am-5pm. This is a toll-free number, so it won’t cost you anything to call.

*To be eligible, you must be insured, in good standing with your insurance carrier, and your claim must not be denied. Other exceptions may apply.

Your Rights and Protections Against Surprise Medical Bills

When you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or must pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that have not signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you cannot control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency Services

If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most the provider or facility may bill you is your plan’s in- network cost-sharing amount (such as copayments and coinsurance). You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

California state law has similar protections to the federal No Surprises Act.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections.

You are NEVER required to give up your protections from balance billing. You also are not required to get care out-of-network. You can choose a provider or facility in your plan’s network.

California state law has similar protections to the federal No Surprises Act.

More information can be found at California Department of Managed Care Surprise Medical Bills Fact Sheet: https://www.dmhc.ca.gov/Portals/0/HealthCareInCalifornia/FactSheets/fsab72.pdf

When balance billing is not allowed, you also have the following protections:

  • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

  • Your health plan generally must:

    • Cover emergency services without requiring you to get approval for services in advance (prior authorization).

    • Cover emergency services by out-of-network providers.

    • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.

    • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact the Centers for Medicare and Medicaid Services at CMS at www.cms.gov for your rights under federal law.

For more information about your rights under California state law, visit California Department of Managed Health Care at www.dmhc.ca.gov or California Department of Insurance at www.insurance.ca.gov.