Understanding Insurance as it Relates to Your Care & Treatment at the CEC
Please note the following refers to the CEC's surgeon's charges only. Hospital, anesthesia and other providers involved in your care will bill separately (and be reimbursed separately) from our Center, including Surgical Assistants Julius Lorinc and Wendy Winer, RN, BSN, CNOR, RNFA, who may provide care during your procedures. We can only speak to our own surgical fees; all other (hospital, anesthesia, surgical assistants, etc.) should all be contacted directly for their specific information. Please note as well; travel and lodging are not part of our quote. Patients are responsible for their own transportation costs.
New: be sure to check out this comprehensive article on excision and insurance
Insurance can be confusing issue - and there may be significant misunderstandings about coverage and how it works with our Center. It is our hope that this information will clarify how we deal with your commercial coverage; however, should you ever have any questions at all, do not hesitate to call us for help (770-913-0001). As always, we accept credit cards, personal checks and Care Credit.
To begin, the Center for Endometriosis Care/Kenny R. Sinervo MD FRCSC, LLC is an out of network provider with all insurance companies. Despite confusion to the contrary, this does not mean we do not accept insurance! This simply means, we will bill your insurance carrier at no cost to you, help with appeals, peer to peer reviews and provide other customary support, but our services will process as an out of network practice. Specifically: as an out of network provider, we do not accept assignment -- we balance bill the patient. You can also click here to learn more about the excision/insurance provider aspect of care.
What does this mean? Those who do not have any out of network coverage are considered self-pay. This includes TriCare. Being an “Out of Network (OON) Provider,” as many other specialists from all areas of healthcare are, means we are not contracted with any health insurance plans – again, it does not mean we do not 'take' or otherwise work with insurance. Unlike many other Out of Network providers, we DO help you gain a common understanding of charges and payments that may be necessary for you to have the best possible experience at the CEC. No one wants surprises, so we do as much financial processing up front FOR you as we possibly can. We will file for coverage/reimbursement, assist you with appeals, provide you with letters of medical necessity as appropriate, and provide any other assistance required on a case by case basis in order to make your experience a smooth one and help you garner the maximum benefits from your coverage. Such service is just one more way that the CEC tries to help our patients. We can only do this, however, based on a proposed surgical plan for you, which is obtained after you've undergone review with the CEC surgeon(s).
To that end, with patients having such large deductibles and out of pocket costs for OON care, even those with insurance might also consider going 'self-pay' to the CEC. Doing so makes patients eligible for self-pay discounts (though contracted payment will be expected in full at least 3 days prior to surgery). Northside Hospital (usually in network for most plans) also offers similar upfront discounts for self-pay patients, as other providers involved in your care may as well.
Why we choose not to participate: insurance companies limit provider decision-making and impact the quality of care you receive. To stay within carrier contracts, we would be required to reduce the quality of care offered to our patients, which we are unwilling to do. We will not compromise the quality of services we offer in order to stay 'in network' with insurance companies; participating as an out of network provider allows us to maintain autonomy and improve the quality of care our patients expect and are accustomed to - and deserve. We believe your treatment decisions should remain between you and your physician, not a bureaucratic entity which does not understand the need for advanced, multidisciplinary expert care for endometriosis and pelvic pain. Seeing an OON Provider simply means that you are seeking care outside of your insurance company's preferred provider network; as such, they pay for less coverage of related services, versus going to an “In Network Provider” - who, while covered, may not be able to provide the focused and expert care for endometriosis that we do.
Our process: First Check: Do you have Insurance, and if so, does it Provide Out of Network Coverage? When you send your records in for our FREE evaluation and review, we request you to send your insurance information as well in your records package. Make a clear copy of the front and back of the card (you might need to enlarge it for legibility). Send your name, date of birth, and social security number, and the name, date of birth and social security number of the cardholder, if it isn't you (your spouse, parent, etc.). This information will let us get some idea of your coverage levels. You can also call your insurance company directly anytime before even sending your records to us and find out what they offer for Out of Network services.
What will be Covered? CEC staff will check your eligibility and benefits. What is covered, and your resulting personal out of pocket costs, will be discussed with you at the time of booking. We will also pre-certify you, if necessary, for your surgery. You will be asked to bring in a specific payment at the time of your pre-op. We work with all patients to try and make excision a real possibility, regardless of your insurance coverage (or lack thereof), including (but not limited to) making possible adjustments, and working one on one with patients on each of their specific situations.
Please let us know how we can help YOU! Call us anytime with general insurance and coverage questions at 770-913-0001.
Did you know…
The CEC staff has presented to legislators in Washington, DC about the critical shortfalls in endometriosis care, among which include lack of reimbursement and coverage for gold standard care. Such meeting(s) have resulted in the first-ever publication of a legislative toolkit for use by all levels of government, which hopefully will lead to improved care on behalf of all women with pelvic pain and disorders.
Patients may also be interested in visiting:
The National Patient Advocate Foundation
OHIP TURNS BLIND EYE ON PATIENT SUFFERING – read about how the CEC is trying to change flawed cross-border policy