NOTICE TO NEW BCBS HEALTHSELECT HME PLANS: Effective As of September 1, 2017, BlueCross BlueShield of Texas (BCBSTX) replaced United Healthcare Services Inc. as the new administrator of health plans for current and retired state employees and their dependents. These changes require more administrative demands before you can be scheduled, which could delay your care. However, we are committed to schedule you for our services as soon as possible. If you are being referred for vestibular testing then your primary care physician is required to obtain a referral from BCBS even if you are being referred by another provider. If you are being referred for physical therapy then we can schedule you but for an evaluation only. We cannot provide treatment until future visits have been authorized from BCBS. Thank you for your patience.
NOTICE: Historically, 360 Balance & Hearing has accepted the majority of insurances. However, it has become increasingly difficult to cover our costs due to poor reimbursement rates combined with the overwhelming administrative demands on our small private practice to obtain pre-certifications and chasing payments for our specialty services. As an in-network provider, we are more obligated to treat patients according to insurance company rules rather than according to your needs or even how you want to be treated.
Below summarizes our current status with major insurance companies:
Below summarizes our current status with major insurance companies:
If you would like to read more from us regarding this decision, please click here.
We have put together the following information to answer some of the more common questions we have received through the years regarding insurance plans.
For most people, health insurance can seem like a foreign land with all of its mysterious twists and turns with terminology such as “adjudication” and “deductible”. So we have created this page on our website to help clarify and simplify what can seem like a daunting and sometime frustrating process.
The general order of the insurance process is as follows:
- 360 Balance will verify your eligibility and benefits with your commercial insurance company on the day before your first visit.
- You may have to pay an over the counter payment for either PT or audiology services.
- After your visit(s), your claim(s) with be sent to your insurance company for processing.
- 360 Balance receives notification of how your claim has been processed either electronically or by mail.
- You may or may not receive a statement for any balance you are responsible for from 360 Balance and Hearing.
Checking Eligibility and Benefits (commercial insurance):
As a courtesy, 360 Balance and Hearing will contact your insurance company to verify what your eligibility and benefits are specific to physical therapy and audiology services so you will know what you may or may not be expected to pay over the counter for your visit(s). We will collect fees according to what your insurance company tells us to on the date(s) of your service(s). Eligibility and benefits quoted to 360 Balance and Hearing by your insurance company is not a guarantee of payment or coverage. This disclaimer is explicitly told to us by ALL commercial insurance carriers at the time of benefit checks to 360 Balance and Hearing. We encourage you to personally contact your insurance company directly to inquire about your coverage (for physical therapy and audiology) and obtain a quote of what you may be expected to pay on the date of your service(s). You may also refer to your written insurance plan summary for assistance.
** It is important to note that most HMO plans require a pre-authorization or pre-certification to be obtained prior to any PT or audiology services from your PCP (primary care provider). If a pre-certification or prior authorization is not completed, your services will not be covered and you will likely have to pay out of pocket. It is the patient’s responsibility to ensure a pre-cert or authorization is or is not required.
Over the Counter Payments Defined
Deductible: an amount of expenses that must be paid out of your own pocket before your insurance company will pay for anything for you on your behalf.
For example, let’s say your deductible is $3000 and our PT follow up visits are $95. You will need to pay us the $95 in order to be seen and treated. We will then file your claim with your insurance company and that amount of $95 will be applied to your deductible dropping your deductible down to $2925. Once your deductible has been met 100% you may then be responsible for a co-insurance payment (%) or nothing at all (depending on your plan). Insurance plans vary greatly from insurance company to insurance company. We do our very best to accurately estimate deductible payments based on our individual insurance contracted rates. We conservatively under-estimate instead of over-estimate.
Co-payments: a specific and set amount that you pay before you meet your deductible. Copays also vary depending on what type of service you are needing.
For example, you may be required to pay a $40 copay at your doctor’s office for each visit, but you may need to only pay a $15 copay for every PT visit. Again, Insurance plans vary greatly from insurance company to insurance company.
Co-insurance payments: a percentage (%) of a provider’s charge that you may be required to pay AFTER you have met your deductible 100%. We do our very best to accurately estimate co-insurance payments based on our individual insurance contracted rates.
For example, if you have a hearing test in our office and your plan requires that you will need to pay 20% for that service ($125 full price), you will expect to pay $22.
Your claim is sent to your insurance company
After your visit(s), your claim is created. Your claim includes your diagnosis codes (ICD10), your service codes (CPT), your 360 Balance treating clinician’s name and NPI, your full legal name, date of birth, address, phone number, the referring MD name with his/her NPI#, and any prior authorization or certification ID #. Your claim is “double checked” for accuracy then electronically submitted to our clearing house (Navicure) who will “triple check” your claim for accuracy. Once your claim is officially ready, the clearing house will electronically send your claim to your insurance company for adjudication. Adjudication is the process of paying claims submitted or denying them after comparing claims to the benefit or coverage requirements. The time frame of the adjudication process varies from insurance company to insurance company.
360 Balance and Hearing receives your processed claim
Most claims process successfully (>95%) without issues such as denials or needing additional information for adjudication. We are able to do this through being diligent with our processes such as checking your benefits prior to your visit, collecting over the counter payments as accurately as possible from the start, and by tediously assessing each and every claim prior to submission to your insurance company. Depending on how your claim processes, you may or may not receive a statement from us.
You May or May Not Receive a Statement
On some occasions, we will need to send you a statement even if you have already paid something to us over the counter. The most common reason for this is because your insurance company did not provide us an accurate quote of your benefits prior to your first visit. We’re not passing the buck, it’s unfortunately an extremely common occurrence. This is why we urge you to contact your insurance company to perform your own benefit check prior to coming to see us. Here are a few common examples of patient billing questions…
Patient: “You said that I only owed a co pay of $10 per visit for PT?”
360 Balance: “Yes, that is what your insurance company initially told us, however your claim ended up processing to show that you were due to pay a co-insurance payment of 20% which is why you received a statement for the balance.”
Patient: “I paid a $100 deductible payment over the counter so why did I still get a bill for $17.98?”
360 Balance: “You received a statement because the $100 was an underestimation of what your services were for that date. We would rather under collect than over collect from you.”
Patient: “I paid a co-insurance payment already (%), why is this bill so much more? My deductible should have been met because my husband just had some blood work done.”
360 Balance: “Yes, that is what your insurance company initially told us, however your $3000 deductible apparently had not been met yet on that date of service.”