Insurance & Billing

In-Network Coverage: When you receive care from a provider who is part of your insurance plan's network, you typically pay less out-of-pocket. In-network providers have agreed to accept negotiated rates from your insurance company, which can significantly reduce your costs.

Out-of-Network Coverage: If you receive care from a provider who is not part of your insurance plan's network, you may have to pay higher out-of-pocket costs. Out-of-network providers do not have negotiated rates with your insurance company, which can result in higher charges.

Tip: Ensure that Sugarloaf Medical PC physicians are in-network with your plan to minimize out-of-pocket expenses and notify us if we are not in your network.

Selecting an appropriate health insurance plan is crucial. Key factors to consider include:

• Premium: The monthly cost for your insurance coverage.
• Co-payment (Co-pay): A fixed amount you pay for specific services (e.g., $30 for a doctor's visit) at the time of service.
• Deductible: The amount you pay out-of-pocket for covered services before your insurance begins to pay. Deductibles can apply to various services, such as office visits, laboratory tests, and diagnostic procedures. It's essential to review your plan details to understand which services are subject to the deductible. It is preferred to choose a plan where the deductible won't apply to office visits.
• Co-insurance: Your share of the costs of a covered service, calculated as a percentage (e.g., 20%) of the allowed amount for the service. Co-insurance typically applies after the deductible is met, unless the plan has no deductible.
• Out-of-Pocket Maximum: The maximum amount you pay during a policy period (usually a year) before your insurance covers 100% of covered services.

It's vital to understand what your insurance plan covers:

• Preventive Services: Under the Affordable Care Act (ACA), many preventive services are covered at no additional cost when provided by in-network providers. These services typically include annual physical exams, vaccinations, and routine screenings. However, if you have existing unstable or uncontrolled chronic medical conditions that need to be managed during the preventive visit, or if you have additional concerns related to an acute issue or symptoms, an additional office visit CPT code will be added to the preventive visit CPT code to reflect the services provided, potentially resulting in additional costs such as co-pays or deductible. Preventive physicals do not include management of existing acute or chronic conditions. Preventive visits do not mean disease management. Patients often schedule a preventive visit expecting to address all their concerns, but patient responsibility applies for non-preventive services. If the patient has a communicable illness, the acute illness will be addressed but the preventive visit will be rescheduled. Additionally, associated labs and diagnostic testing may not be considered preventive, and patient responsibility may apply.
• Covered Services: Familiarize yourself with services that require co-pays, co-insurance, or are subject to the deductible. This includes understanding coverage for office visits, laboratory tests, diagnostic imaging, and specialist referrals.
• Prior Authorization: Some services, such as certain testing like ultrasounds, may require prior approval from your insurance company. Many medications may also require prior authorization from the payer, and some may be plan exclusions and won't be covered by the payer. Verify these requirements to avoid unexpected expenses.
  

Note: Coverage means the service is permitted or allowed by the payer, but does not mean payment. Patient responsibility may apply. The better question to verify with the payer is, "What is my patient's responsibility with this service instead of if the service is covered?" Sugarloaf Medical PC does not determine your insurance benefits or out-of-pocket responsibilities. These are defined by your insurance plan. For specific questions about coverage, please contact your insurance provider directly.

Understanding the billing process can help you anticipate and manage your financial responsibilities:

• Service Provision: You receive medical services at Sugarloaf Medical PC.
• Claim Submission: We submit a claim to your insurance company detailing the services provided, using standardized codes known as Current Procedural Terminology (CPT) codes.
• Insurance Review: Your insurance company reviews the claim, determines the allowed amount for each service, and calculates your financial responsibility based on your plan's terms.
• Explanation of Benefits (EOB): After processing the claim, your insurance company sends you an EOB, outlining what was billed, what they paid, and what you owe.
• Patient Statement: If there's a remaining balance after insurance processing, Sugarloaf Medical PC will send you a patient statement indicating the amount due.

An EOB is a statement from your insurance company that explains how a claim was processed. It explains payments and patient responsibilities as determined by the plan. Here's an example of an EOB for a visit that included both a preventive physical exam and an office visit for chronic condition management:

Definitions:

• Amount Billed: The amount charged by the healthcare provider for the service.
• Allowed Amount: The maximum amount your insurance plan agrees to pay for a covered service.
• Adjustment: The difference between the amount billed and the allowed amount.
• Deductible: The amount you pay out-of-pocket before your insurance begins to pay.
• Co-pay: A fixed amount you pay for specific services at the time of service.
• Insurance Paid: The portion of the allowed amount paid by your insurance company.
• You Owe: Your out-of-pocket cost, which may include co-pays, co-insurance, or amounts applied to your deductible.

In this example:

• The Preventive Physical Exam is fully covered under the ACA, so you owe nothing.
• The Office Visit for chronic condition management is considered separate from preventive services, resulting in a $30 charge to you, as determined by your insurance plan.

If there's a balance after your insurance processes the claim, you'll receive a patient statement from Sugarloaf Medical PC. This statement will detail:

• Previous Balance: Any unpaid amounts from prior visits.
• New Charges: Recent services provided and their associated costs.
• Insurance Payments/Adjustments: Payments made by your insurance and any adjustments based on our agreement with them.
• Patient Responsibility: The amount you owe after insurance payments and adjustments.

It's important to note that the patient statement reflects the amount owed as determined by your insurance and explained in the EOB. Sugarloaf Medical PC does not charge for the adjustments; we only charge for the patient responsibility as determined by your insurance plan. If a claim is denied due to inactive insurance, incorrect information provided, resulting in timely filing issues, or non-covered charges, then the entire balance becomes the patient's responsibility.

Sample Patient Statement:

Total Due: $126

Payment options include online payments through our patient portal, by phone, or in person. We encourage patients to opt-in for electronic statements versus paper statements. You will receive SMS text messages with the balance first and are encouraged to pay your balance as soon as the text is received. Remember, an EOB explains payments and patient responsibilities as determined by the plan.

Office visits are categorized based on medical complexity.

New Patient Codes:

Established Patient Codes:

Preventive visit codes are only covered by insurance without patient responsibility. However, labs and other diagnostic testing may not be covered, and deductible or co-insurance may apply. An office visit can be combined with a preventive visit code.

Preventive visits focus on routine health maintenance and are often covered at no cost under many insurance plans. Preventive CPT codes are based on age of patient.

New Patient Codes:

Established Patient Codes:

Ultrasound procedures are commonly used for diagnostic imaging. Relevant CPT codes include:

General Radiology Codes:

Cardiovascular Codes:

These diagnostic services may be subject to deductibles and co-insurance, depending on your insurance plan.

Various diagnostic tests performed in a primary care setting have specific CPT codes:

Coverage for these procedures varies by insurance plan and may involve deductibles or co-pays.

Laboratory tests are integral to preventive care and diagnosis. Common lab test CPT codes include:

While some preventive screenings may be covered without cost-sharing, diagnostic and laboratory tests often apply to your deductible.

Understanding Your Recent Bill: Code G2211

You may have noticed a charge on your recent bill or explanation of benefits labeled "G2211." We want to help you understand what this code represents.

What is G2211?

G2211 is a billing code that reflects the additional complexity involved in caring for patients with whom we have an ongoing relationship. This code was created by Medicare in 2024 to recognize the extra work involved in providing continuous, coordinated care over time.

Why am I being charged for this?

When your doctor provides ongoing care for you—managing your medical conditions over months or years, coordinating with specialists, knowing your complete health history, and addressing multiple health concerns—this adds complexity to each visit beyond what's captured in the standard office visit code. G2211 helps ensure we're appropriately compensated for this comprehensive care.

Does this mean my bill will be higher?

Your insurance plan determines your out-of-pocket costs based on your specific coverage, deductible, and copayment structure. G2211 is recognized by Medicare and most insurance plans as an appropriate part of billing for complex, ongoing care. Any changes to your bill reflect more accurate coding for the type of comprehensive care you receive.

What does this mean for my care?

Nothing changes about the quality or type of care you receive. This code simply ensures that the billing reflects the true complexity of managing your health over time. It supports our ability to continue providing you with thorough, coordinated primary care.

Patients must present an active insurance card at each visit and ensure we have the most up-to-date insurance information on file. Insurance cards may be submitted electronically through our secure system or emailed to us. Without active or accurate insurance details, claims cannot be filed properly, and the patient will be responsible for all charges.

Coordination of Benefits: Patients with multiple insurance policies must designate one as primary and the other as secondary before receiving services to ensure proper claim processing. Denials due to timely filing issues caused by delays in providing the information to the insurance will become the patient's responsibility.

In-Network Providers: If Sugarloaf Medical providers are not in-network with your specific plan, please let us know immediately.

Healthcare Services and Insurance Benefits: We provide care based on medical necessity and established standards of care. Patients are responsible for understanding their insurance benefits, including:

• Deductibles and coinsurance responsibilities for primary care services and procedures.
• Coverage details for services from third parties, such as laboratories, radiology centers, and specialists.

Payment Responsibility: Patients are responsible for the following out-of-pocket costs:

• Copayments
• Deductibles
• Coinsurance
• Charges for non-covered services

To keep accounts in good standing, payments should be made at the time of service or upon receipt of an invoice. For procedures in the office where the deductible applies, the balance will be collected prior to the service.

Payment Methods:

• Online Payments: Secure payments can be made through our patient portal or via Healow Pay.
• Phone Payments: Call our office at 770-831-3018 to make a payment.

Payment Types:

• Cash Payments: Accepted in person at our office.
• Credit and Debit Cards: We accept MasterCard, American Express, Discover, and Visa. Patients may opt to keep a card on file to avoid late fees; stored cards will be charged on the 28th day after the statement date (or the next business day if it falls on a weekend or holiday). Keeping a card on file ensures timely payment and helps avoid late fees.
• Personal Checks: Checks should be made payable to Sugarloaf Medical, P.C. A $50 service charge applies for any returned checks. If a check is returned, future visits may require payment via cash or credit card.

Telehealth Services: Sugarloaf Medical, P.C. offers telehealth visits for established patients only. Telehealth charges apply to:

• Audio-Video Telemedicine Visits: Virtual visits conducted via secure video conferencing for evaluations, diagnoses, and treatment planning.
• Audio-Only Telemedicine Visits: Phone consultations for follow-ups, medication management, and general health inquiries.
• Electronic Assessments and Messaging: Secure provider communication, including responses to medical questions, prescription refills, and test result reviews.

Please note that telehealth services are chargeable, and patient responsibility may apply based on your insurance plan.

Patients without insurance or those who choose not to use their insurance will be considered self-pay. A base charge of $200 will be collected upfront to cover the visit. Any additional charges from labs, diagnostic testing, or vaccines will be added and collected at checkout. Full payment is expected at the time of service.

Payment Plans: For self-pay patients, 50% of the balance is due within 30 days of the invoice, and the remaining balance is due over the next 90 days (120 days from the invoice date). If an additional balance is incurred before making full payment, the patient may apply to transfer the balance to CareCredit. Delinquency in payment will result in transferring charges to collections.

At Sugarloaf Medical, P.C., we understand that medical expenses can be challenging to manage. We offer various payment assistance options to help you cover your healthcare costs.

Payment Plans: We provide flexible payment plans to make it easier to manage your medical bills. Here are the details:

Short-Term Payment Plans (Up to 90 Days): We offer 90-day interest-free payment plans for eligible balances. This means you can spread your payments over three months without incurring any interest charges. To set up a short-term payment plan, contact our billing department. They will assist you in arranging monthly installment payments that fit your budget. For self-pay patients, 50% of the balance is due within 30 days of the invoice, and the remaining balance is due over the next 90 days (120 days from the invoice date).

Example of a Short-Term Payment Plan:

Extended Financing with CareCredit (Up to 18 Months): For balances exceeding 90 days, we partner with CareCredit to offer extended financing options. CareCredit allows you to pay off your balance over a longer period, up to 18 months.

Key Benefits of CareCredit:

• 0% Interest for up to 18 months: If you pay the full balance within the promotional period, you won't be charged any interest.
• No upfront fees or prepayment penalties: You can start using CareCredit without any initial costs, and you won't be penalized for paying off your balance early.
• Flexible monthly payment options: Choose a payment plan that works best for your financial situation.

Example of an Extended Financing Plan with CareCredit:

💡 Sugarloaf Medical P.C. covers the interest on CareCredit plans, allowing you to extend payments at no additional cost to you.

How to Apply for CareCredit:

• Online Application: Visit the CareCredit Application Page to apply online.
• By Phone: Call CareCredit at (800) 677-0718 to apply over the phone.
• In Our Office: Our staff can assist you with the CareCredit application process during your visit.

Balances not paid within 30 days will incur late fees. If the balance remains unpaid after 90 days, additional collections fees will apply, and the account will be sent to collections. It is important to settle your balance promptly to avoid these extra charges.