Patients First- Price Transparency Law

On January 1, 2021, Governor Baker signed An Act Promoting a Resilient Health Care System that Puts Patients First (“Patients First”) into law which makes significant changes to the state’s healthcare laws. In a continued effort adhering to the new healthcare laws, our office will have changes relating to insurance, credentialing, and will continue to be as transparent with patient billings for services within our office. 

Patient-First Price Transparency

What does this mean for our patients?  

Adhering to the new laws put into place effective 1-1-2022, all patients will have advance access to estimates for scheduled visits. If you would like to discuss estimates, please contact our billing office prior to your visit.  Additionally, a listing of our services, along with CPT (Procedure Codes) and pricing information has been included for your review by clicking here. If you would like to have a better understanding of how your insurance plan will process a specific visit type, or code, we welcome you to discuss the services with your insurance plan directly. 


In-Network Referral Confirmation:
If your provider decides to refer you to a specialist, your care will be referred to the specialists participating in the Lowell General Hospital PHO. Confirming that your insurance policy is a plan in our approved Contracted Insurance Plans, will help ensure that your plan is also accepted within our referral network. For more information on our referral network, please click here

Out-of-Network Insurance Coverages:
In a continued effort to adhere to the new healthcare laws, we will continue to work our best with respect to out-of-network insurance coverage. Please be sure to visit the Insurance tab to confirm if your plan is listed. Our Billing office is also available to help confirm whether your insurance is part of our accepted contracted plans. When a patient is seen with out-of-network coverage, this means that you will  have higher out of pocket costs with our office than if you were to receive care from an in-network provider in your health plan. It also would result in the inability to confirm whether any referred providers or services would be an approved provider within your health plan. If you are identified as having out-of-network benefits, our office will work with you on proper estimate information before your appointments so that you can make an informed choice on your healthcare. If at anytime you may think a visit within our practice processed with out-of-network benefits without prior knowledge, please contact our billing team and we will investigate all inquires. 

Uninsured or Self-Pay Patients:
At this time patients who are currently uninsured or known as a "Self-Pay" status will be presented with advanced maximum estimate of their services, based on the description of their appointment. If any additional services are discussed/reviewed when with the provider, our team will be sure to communicate any pricing changes affected to that day's visit in an effort to keep the patient informed and allow for continued consent of treatment. Payment will be required at the completion of your visit during the check-out process.  Our Office will maintain a singular Price Listing as another continued effort in price transparency. These prices will be the same for all patients, regardless of insurance plan, type, or uninsured status. The only reduction accepted will be the legal contractual adjustments that may only be set by an insurance company. To review our Price list of services, click here. 

 

Patient Cost-Share / Understanding your Benefits 

 

One of the most common problems that people experience with their health insurance is the frustration of having to pay out-of-pocket for a service that they thought would be covered by their insurance plan. While a service may be covered by your insurance, your visit may still result in patient cost-share, in the form of a

deductible/co-insurance/or copay responsibility. 

 

All insurance plans are unique; even when reviewing two plans from the same insurance. Because of that, it is quite difficult to make a single guide that covers all aspects of your coverage.  With that in mind, our hope is to help you understand the thought processes and terminology behind determining your plan’s details so you can navigate through your own insurer’s information and have a better understanding of your individual coverage and benefits.  Knowing your plan's benefits will keep you from unexpected bills, allowing you to take full charge of your healthcare. 

 

Types of Patient Cost-Sharing 

 

Copay: In a traditional copay plan, you pay a fixed amount per service. For example, if your copay is $40 for Office Visits, you are expected to pay $40 for each visit within our office. 

 

Coinsurance: In a coinsurance model, you pay a fixed percentage of each service. For example, if your coinsurance is 20%, you would pay 20% of the insurance's allowed price for the service. The amount of an applied coinsurance will be determined after the insurance company has finalized the processing of the visit.  

 

Deductible: With a deductible, you pay the entire amount allowed for all services provided until the deductible is met. The deductible starts over every plan year. 

 

Out-of-pocket maximum: This is the absolute maximum you are expected to pay in cost sharing within a plan year. In contrast to your deductible, the out-of-pocket maximum refers to your cost sharing arrangement after your deductible has been met. 

 

How can I find what my covered benefits are or what cost-shares may be applied to my visits?  

 

There are several methods you can use to figure out your plan’s details for a particular service and the types of benefits you can expect to receive. With the advancement of technology, being able to access this information is easier than ever before. 

 

1. If you are computer savvy, consider enrolling in your insurance plan's online member portal. Online portals will hold a vast amount of information, and best yet, the information should be specific to your individual insurance plan. Review your copay expectations, whether you have a deductible to meet, and you can expect as a patient cost-share from a variety of services. With some portals, there are even options to submit an estimated visit request online and your plan will research and provide you with an potential breakdown for that visit, including patient cost-share if required. 
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2. If you prefer to speak with someone directly, you have access to member service representatives. On the back of your insurance card, there should be a customer service number that you can use to ask any questions you may have about your plan. When speaking with your representative, request an explanation regarding any service or visit you would like clarification of benefit.