We do not participate in (or contract directly with) any insurance company plans, HMOs, PPOs or other alphabets. Read more on the Insurance Claims page.
If you have insurance, we will provide you with the documentation you need to file your claim in the form of an itemized invoice that lists all services and diagnosis codes.
We request that you ask your insurance company to send the reimbursement check to you, not us. If the insurance company errs (some do), and sends a check naming us as the payee, we write a check to you for the same amount.
The reimbursement from the insurance company belongs to you. Not us. The payment is a reimbursement, to you, paid to you after you pay us.
We cannot provide the documentation you need to file your insurance claim until after you have paid us, of course. (You can't ask your insurance company to "reimburse" you for something you haven't paid yet.)
We cannot guarantee what your reimbursement will be, but our patients - and we - have been pleasantly surprised to learn that our low-cost labs offset our occasionally higher-cost (longer, more time spent) professional services. You may well break even, or close to it, and gain the benefit of having personal control over your health care.
Why we don't participate in HMOs, PPOs, and other insurance-driven networks
Managed Care doesn't work. It not only doesn't work, it's not even profitable, which was the driving point in the first place.
"I recall vividly," Dr. Vaughan says, "back in the mid-1990s, the American Hospital Association funded a study that was expected to conclude that hospitals were the best organizations to manage health care. The study concluded, to their embarrassment, that physicians were the best people to manage health care.
"This came as no surprise to me. In numerous speeches, I tried to explain to my audiences that the very essence of medical training is not to throw everything you have at every illness. Cost-effectiveness is drilled into every medical student.
"I used the example of a 30-year-old man coming to the Emergency Room, complaining of chest pain. If you gave an EKG to every such patient, you would bring the entire health care system in America to a grinding halt in a single day. You would either bankrupt every insurance company, or bankrupt every hospital, or both. Yet, a microscopic percentage of those 30-year-olds would, indeed, suffer a heart attack - perhaps because of a congenital defect. Physicians are trained to use the most cost-effective approach in treating every illness, minor and major.
"Now, insurers, HMOs and all the other insurance-driven networks, are finding that the best providers of the most cost-effective health care are, indeed, physicians. Yet they, and the government, continue to tinker with the system.
"Once, we had major medical coverage. It made sense. It covered you for disasters, just like your fire insurance on your house. But do you expect your fire insurer to pay for the 89-cent batteries in your smoke detectors? That's what we expect from health insurers, and it doesn't make sense.
"I believe totally in the need for major medical coverage. But not in coverage for trivial costs, and not in managed care, which doesn't manage anything, but just creates costly paperwork, which impedes the efficient delivery of health care.
"I think patients should be entitled to make health care decisions in partnership with their physicians. If the physician is practicing on the leading edge, the physician shouldn't have to fight some unknowing clerk to get approval for a soundly researched, fully tested, procedure that just, by chance doesn't happen to come up on the clerk's computer.
"I also believe physicians should be able to tell their patients what health care will cost. This is impossible under the present system. With Procedure Codes now numbered in the tens of thousands, subject to review and change at several levels from treatment to payment, it's impossible to know what a simple office visit will cost. Really. It's impossible to know in advance.
"Worse, we can't predict what your insurance company will reimburse. We subscribe to survey services, but even with that, insurance reimbursements are completely unpredictable."
We provide the documentation you need to file your insurance claim
We are 'Out of the Network'
We're not controlled by any insurance company.
We have no contracts with any insurance companies, HMOs, PPOs, and the like. Nor do we participate in the Medicaid or Medicare programs.
We don't contract with any insurance company. We contract with you, our patient.
We expect payment on day of service, from you, the patient.
We work for you, not for your insurance company. This gives us freedom to develop patient care and treatment plans without third-party interference.
The only people who will approve your treatment plan are you and your physician.
After you have paid for each visit, we will provide you with the documentation you need to file your claim for reimbursement for that visit. You, the patient, are responsible for obtaining any reimbursement paperwork that your insurance company may require.
Reimbursement to you, not us
We encourage you to ask your insurance company to send the reimbursement check to you, not us.
We cannot guarantee your reimbursement
We cannot guarantee that your insurance reimbursement will cover all costs of health care services in our office, since we have no control over the type of insurance coverage you may have.
Policies differ - there are thousands of different kinds. What your policy will pay for a particular visit is something we cannot predict. Your insurance company won't tell us - or you, for that matter.
The magic words are 'Out of Network'
Call your insurance company. Tell the company your policy number. Then ask them, "Does my policy cover 'Out of Network' medical care?"
(Many, perhaps most, policies cover Out of Network care - but you should be sure yours does, if your financial situation demands that you get reimbursement for your medical care.)
Then ask, "What is my annual deductible for Out of Network medical care?"
(Here's why you ask that question: Blue Cross Blue Shield advertises that you can choose your own doctor - freedom of choice. What they don't say in the ads is that some of their policies have a $5,000 deductible if you take them up on their seemingly gracious offer. So, ask the question. And if you have BCBS, and your policy punishes you for choosing your own doctor, consider getting a different policy.)
Questions about insurance claims
Please call or email us. Please bear in mind that insurance companies don't always tell us the whole truth - so what we pass on to you may be our best guess as to what they really meant when they answered our question.
Lab charges and other ancillary services
We can't predict what lab tests you will need. That's why we can't possibly estimate - in advance of a visit and examination - what they are likely to cost.
And we can't predict what services you will need.
If you need lab tests, we ask you to pay for them. When the need arises. Only if the need arises.
We have the services available, and our charges for them are reasonable. Your insurance policy (if you have one) should reimburse you for them at the rates provided for in your insurance policy.
While we endeavor to obtain laboratory services, and provide ancillary services, at rates that may be significantly less than you might pay elsewhere, we cannot guarantee specific savings. And we can't - for sure, we can't - predict how much your insurance plan will reimburse. So far, patients tell us the reimbursements have been extraordinarily good.
For laboratory tests, we charge our cost plus processing
We have negotiated some rather good prices with our laboratories. We pass on those savings to you - not your insurance company.
You need to know, though, that while we do order common tests, we may also order labs that are so leading edge they may not even be in your insurance company's database. We'll tell you first. You decide.
Anytime we propose labs, we are more than willing to discuss the cost with you beforehand. If you wonder, please ask.
For Ancillary Procedures, we charge our cost plus processing
When we say ancillary procedures, think things like: Casts. IV Therapy. B12 shots. Removing warts or skin tags.
We charge what we consider a reasonable fee, near the median for this area, and that fee is usually close to what surveys indicate insurance companies will reimburse - but we cannot guarantee reimbursement.
We are happy to tell you in advance what we will charge. But please don't ask us to predict what lab tests we will need to order if we haven't seen you yet (people do that).
Payment for laboratory tests and ancillary services due on Date of Service
We expect payment for laboratory tests and ancillary services at the time of service, unless other arrangements have been made. One way we can afford to deliver superior service is to reduce administrative costs. And sending bills is an administrative cost we want to avoid.