Insurance, PAYMENT & COST INFORMATION
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INSURANCE INFORMATION
Insurance can be a confusing issue and there may be significant misunderstanding about coverage and how it works with our Center. It is our hope that this information will clarify how we deal with insurance coverage; however, should you have questions, do not hesitate to call us at 770-913-0001. To begin, the CEC is an insurance-friendly, out of network (OON) provider. We also have preferred rates for various companies.
What this means in simple terms is, you are seeking care outside of your insurance company's preferred provider network. This is often the case with many medical specialists. As a result, your insurance may pay for less coverage of services versus going to one of their “in network providers” - who, while covered, may not be able to provide the focused and expert care for endometriosis that we do.
This does not mean we do not accept insurance, and we are not ‘cash only’. This simply means, we will file a claim on your behalf as a courtesy and appeal for coverage/reimbursement after the initial claim has been filed/denied. We will also provide other reasonable assistance on a case-by-case basis to try to help you get the maximum benefits from your coverage.
Our services will process as an out of network practice. It is recommended that you connect with your insurance prior to seeking care with our Center to understand your insurance policy and know if you have coverage so there are no surprises. Please remember, each patients' insurance policy is different. We could have Patient A with BCBS and Patient B with BCBS, and reimbursement on their claims may be totally different. Just like you should be your own patient advocate, you should also be your own advocate with your insurance company and be prepared to appeal on your own if our appeal is not successful.
Also, unlike many other endometriosis centers, the CEC takes the time to check your eligibility and benefits. We will provide you with an estimate, based off your surgical plan and will discuss it with you in full prior to surgery. Once you have your surgery date, we will then verify if an authorization is needed for your procedure codes. We will also pre-certify you, if necessary, for your surgery. Please note that authorization is not a guarantee of payment, and all patients are asked to bring in a specific payment at the time of their pre-op. The amount depends on the specifics of your case.
TriCare, Medicare and Medicaid, Kaiser, Ambetter and CHAMPVA (VA champ) are automatically considered self-pay with the CEC.
Although you may not have any out of network coverage for our surgeons, the hospital (which comprises the largest part of the costs) and any associated providers may be considered in-network, and you can use your insurance policy to cover their charges. We can only speak to our own surgical fees; all other (hospital, anesthesia, surgical assistants, etc.) should be contacted directly for their specific information.
Please note as an out of network provider, we do not accept assignment. We bill the patient up to their out-of-pocket maximum, which varies by case.
COSTS OF SURGERY
Our surgeries range between $5,000 to our maximum out of pocket cost of $21,500 and are dependent on the complexity and length of the case.
We do not know what your specific cost will be before reviewing your case and working up the procedures you will need. Some insurance coverage is better than others, and so we are able to offer preferred rates to those subscribers. For example:
BCBS, UMR & UHC:
Out of pocket costs to the patient typically range between $5,000-$14,500.
Aetna:
Out of pocket costs to the patient range between $7,500-$14,500.
Humana & Cigna:
Out of pocket costs to the patient range from $10,000-$21,000.
Self Pay (Medicaid, Medicare, Tricare, Kaiser and others like Molina and Oscar, or Medishare plans) are a flat rate, based on the surgical plan, and range between $11,000-$14,500.
Travel and lodging are never part of our fee quote. Patients are responsible for their own transportation and accommodation costs as well as any supplemental care e.g., home health aide, nursing services, etc.
In very limited and specific circumstances, we may provide income- and asset-based discounts to qualified patients on a highly case-specific basis for those who meet select financial criteria.
ACCEPTED FORMS OF PAYMENT
We accept CareCredit (apply at link), Visa, Mastercard, Discover, and Cashier’s Checks. No personal checks or cash, please.
More information on “Surprise Billing” and “Balance Billing” from the US Centers for Medicare & Medicaid:
https://www.cms.gov/files/document/nosurpriseactfactsheet-final508.pdf
Why We Elect not to Participate as an “In-network” Provider:
We are a small private practice, not a large academic medical center or hospital offset by reimbursement structures and other operating revenues. As a private entity, to stay within carrier contracts, we would be required to reduce the quality of care offered to our patients in order to adhere to utilization management requirements, which we are unwilling to do. We will not compromise the quality of services we offer in order to stay 'in network' with a bureaucracy; participating as an out of network provider allows us to maintain autonomy and ensure the quality of care our patients deserve. We believe your treatment decisions should remain between you and your physician, not an entity that does not understand the need for advanced, multidisciplinary expert care for endometriosis and pelvic pain.
Did You Know…?
The CEC team has presented to national legislators including in Washington, DC about the critical shortfalls in endometriosis care. Those efforts have included substantive discussions about the failed coding and reimbursement structure surrounding endometriosis treatments and poor disease guidelines, both of which pose significant barriers to accessing gold standard care for everyone seeking treatment. We are also represented on institutional coding committees seeking to make significant changes and ultimately recognize the subspecialty of endometriosis to remove those financial barriers for patients. Of course, we also donate a number of surgeries and work with our patients year-round to increase access to our own Center. Excerpted from "Low payments for excision surgery frustrate physicians, patients" (previously featured on the Endometriosis Journey, a project of MDEdge) by the leading medical writer, Alicia Gallegos:
"Similar challenges are playing out in practices across the country as surgeons try to manage the relatively low insurance payments for certain complex endometriosis-related surgeries, as well as the often time–consuming paperwork demands that come with seeking appropriate payments and coverage for patients...A spokeswoman for America's Health Insurance Plans (AHIP) would not comment specifically on coverage for endometriosis excision surgery. Health plans generally have individual policies regarding how they handle such treatments, said Kristine Grow, senior vice president of communication for AHIP. "Typically, they evaluate requests for new treatments on a case-by-case basis in the context of an expert review of all available evidence to make a coverage determination," she said in an interview. The absence of a specific billing code for endometriosis excision contributes significantly to poor payment for the procedure, surgeons said. Currently, excision is generally billed under CPT code 58662, which refers to the destruction or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method. This means that insurers view a full and complex excision of endometriosis as comparable to a superficial ablation procedure, said Ken Sinervo, MD, medical director for the Center for Endometriosis Care in Atlanta, which operates on an out-of-network basis. "There's a huge difference between ablating something and excising something," Dr. Sinervo said.