INSURANCE

Health insurance, as you probably know, is very complex, and it seems to be getting even more so lately. There are many different companies, and each company may offer many different coverage options. Our office participates in traditional Medicare and many private plans including all the New Jersey Horizon Blue Cross/Blue Shield plans, Aetna, Qualcare, United Healthcare, Prudential and many others. As a specialty practice, we may provide care for patients who come to us on their own or who come on referral from their primary care physicians.

The concept of "participating" may be confusing to some. Basically, it means that for any service we provide which is covered by your insurance plan, we will submit the claim directly to the company for payment. Your responsibility would be limited only to either a copayment or a deductible, if there is one.  We have used the term relating to services which are covered. What this means is that if your company denies payment for a service we provide because it is not covered by the insurance plan, then you will be responsible for the payment to us.

Unfortunately, in many cases, we have no way of knowing in advance of the specific details of your plan's coverage.  Thus, a service may be covered by one company or one plan but not by another. What may appear to be two identical plans may represent two entirely different coverage items. For example, many plans cover you for a routine eye exam when you have no medical eye problems. Other plans do not cover you for this. If your visit with us is just for a routine checkup with no medical eye problems, and your plan does not have "routine" coverage, you would then be responsible for the exam.  Most insurance companies will not accept a diagnosis of "blurry vision" as a medical problem. Quite often we see patients who come in complaining of blurry vision and a concern that the blur might be from some disease such as cataract, glaucoma or macular degeneration. If there is no disease present, and it turns out that the blur is purely related to eyeglasses, your insurance company MIGHT not cover you, even though you came in because you thought you had a medical problem. This has been a very difficult issue for us. Insurance coverage is frequently based upon the actual diagnosis, NOT the one you feared you might have. Please understand that we have no control over what coverage you have. We must, by law and by good ethics, be truthful in our insurance claims.

Another problem arises because some plans require that you obtain a written referral from your primary care physician before coming to us. Many of these we know about, but some we do not. Once again, therefore, it is YOUR responsibility to know if a referral form in needed and to provide it PRIOR to your being seen unless, of course, there is an emergency situation.  Please note, therefore, that if your plan requires a written referral form and you do not have it with you, we will certainly still see you as a patient, but you, not your insurance company, will be responsible for the bill. Some primary care doctors will issue referral forms "after the fact" (such as the next day), but many will not.

We will do our best to make sure that you receive all the insurance coverage to which you are entitled.  If you request extra services from us that ordinarily might not be included with the service that is covered by your insurance company, then you will be responsible for charges arising from that service.

Finally, in recent years, with the increasing numbers of managed care plans, we have noted that patients often change insurance companies frequently. Please understand, therefore, that we need to verify your insurance plan on each visit so that our records are correct. If we have outdated insurance information, it will only cause delays in processing or result in our sending bills to you that should be paid by your company.

Please do not hesitate to ask us if you have questions. Our business office staff ( 732 988-4949 ) is very knowledgeable and will be happy to assist you as best we can.

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