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    Insurance and Billing Frequently Asked Questions

    What is the difference between an HMO, PPO and EPO?

    HMO (Health Maintenance Organization): The patient is assigned to a primary care physician (PCP) who is responsible for managing the patient's care and providing referrals for specialty care.

    If you have an HMO and are not assigned to the Palo Alto Medical Foundation (PAMF), services at PAMF will not be covered. If you wish to change your assignment, please contact your insurance provider.

    PPO (Preferred Provider Organization): The patient is not required to select a PCP or group, but must seek service within the contracted network. Services outside of the network could result in higher out-of-pocket expenses.

    EPO (Exclusive Provider Organization): This patient is assigned to a PCP but has more flexibility in opting out of the network. This could result in higher out-of-pocket expenses.

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    Does PAMF accept my PPO/EPO insurance?

    PAMF is contracted with most major insurance products available in the community. To find out if PAMF is contracted with your insurance, please call an account specialist at (888) 398-5677. Monday – Friday, 8 a.m. – 5 p.m. PST or visit us online.

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    What is the difference between a physical exam and an office visit?

    Physical exam: A preventative health maintenance exam during which your physician takes your relevant medical and family history; asks pertinent screening questions; and performs or orders appropriate screening tests based on your age, sex and medical risks to evaluate your overall health.

    Office Visit: A problem-related visit that addresses a specific health problem through discussion, examination, diagnosis and/or testing. Treatment is prescribed as necessary.

    If you are a medicare patient, other terms apply. Please refer to our Medicare Patients page for important information regarding your Medicare coverage.

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    Why do I need to make a co-pay? What is the difference between co-pay, co-insurance and deductible?

    Health insurance seldom covers 100 percent of your health care costs. Costs that are not covered by insurance are called out-of-pocket expenses. There are generally three types:

    1. Co-pay: Fixed dollar amount required at the time of service for certain benefits. If your insurance plan includes co-pay, PAMF is required by contract with your insurance provider to collect a co-pay at the time of your appointment. Please be prepared to present payment when you check in for your appointment.
    2. Co-insurance: A percentage of cost the insurance company has predetermined as patient responsibility.
    3. Deductible: A fixed dollar amount a patient must pay before insurance will cover any costs.

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    What is the difference between a referral and an authorization? If my procedure is authorized, will I have to pay?

    Referral: A request to transfer your care from one provider to another (usually for specialty services).

    Authorization: Approval from your insurance company to pay for specific services before they are provided.

    An authorization does not guarantee full payment for the procedures. Authorization simply means that your insurance company approves the service to be medically necessary. Your insurance plan determines how much you'll have to pay for services.

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    Why did my doctor charge for two services at one appointment? Why can't they be combined?

    Your bill reflects services your physician has provided and documentation. If you receive treatment for a problem-related issue during your physical exam, your physician is required to document and thus charge for these services. Health insurers do not consider preventative care and problem-related treatment the same service; therefore, the insurer pays for them separately.

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    I am concerned about the cost of my health care. Does PAMF offer any financial assistance or special payment programs for patients?

    PAMF patients may be eligible for the following payment programs:

    • Financial Assistance Program: Helps with the cost of medically necessary services for patients whose income is 200 percent below the Federal Poverty Guideline and who do not have medical insurance. The amount is determined each year and can be found at: Federal Poverty Guideline
    • Payment Plan: If the patient is unable to pay his or her balance in full by the end of the billing cycle, the patient may enroll in a payment plan.
    • Prompt Pay Discount: Self-pay patients (patients without insurance) may receive a 30 percent discount on services received if paid in full within 20 days after receiving their statements. The discount does not apply to cosmetic procedures, co-pay, deductibles or co-insurances.
    To inquire about any of the above programs, please call (877) 252-1777, 7 a.m. – 7 p.m. PST.

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    How do I know what services are covered by my health plan? Does my insurance cover travel vaccinations, mental health services, sports or pilot physicals, or work-related accidents?

    If you have questions about your health insurance coverage, we recommend that you speak to your insurance provider. With so many health insurance plans in the market, it is not possible for our front desk staff to identify each plan's details of coverage or predict which services your physician will perform in the exam room. If you are seeking travel vaccinations, a sports or pilot physical, and/or mental health services, it is best to contact your insurance provider prior to scheduling an appointment. Sometimes these services are given different coverage. If you need to be seen for a work-related accident, it is best to first contact your employer. There is usually a specific provider your employer is contracted with that will offer workers' compensation services.

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    My insurance company told me to ask my health care provider to change a code on my last insurance bill. What should I do?

    Your bill reflects services that your physician provided and is required by law to document accurately. The documentation is assigned codes, which are governed by state and federal agencies. Changing a code in order to have the service covered by a patient's insurance can be considered fraud.

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