Insurance & PAYMENT INFORMATION
Are you a CEC patient looking for your account to make a payment? Click here
If you are looking for insurance and payment option information, please read on.
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 your coverage; however, should you have questions, do not hesitate to call us at 770-913-0001.
The CEC is an insurance-friendly, out of network (OON) provider:
-Seeing an OON Provider means you are seeking care outside of your insurance company's preferred provider network (as is the case routinely with other medical specialists); as such, they often 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. This does not mean we do not accept insurance, and we are not ‘cash only’. This simply means, unless you are a self-pay patient, 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 garner 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.
-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 detail at the time of surgical booking. Once you have a surgery date, we will then verify if an authorization is needed for your procedure codes. Authorization is not a guarantee of payment. 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. The amount depends on the specifics of your case.
-Please note we do not file for in-network exceptions. As well, 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.
-While our fee range is capped, we do not know what your specific costs will be before reviewing the specifics of your case.
-Although you may not have OON 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. You will need to check with Northside Hospital directly.
TriCare, Medicare and Medicaid, Kaiser, Ambetter and CHAMPVA (VA champ), please note:
-We cannot file insurance claims for patients who have asked to be treated as self-pay. Those with TriCare, Medicare and Medicaid, Kaiser, Ambetter and CHAMPVA (VA champ) are automatically considered self-pay with the CEC, thus waiving the ability to file with their insurance carrier.
Self-Pay:
-Those who do not have any insurance, have Tricare, Medicare, Medicaid, Ambetter, Kaiser or ChampVA, or who have no out of network coverage are considered self-pay.
-Patients with very high deductibles or who otherwise come to the CEC as a "self-pay patient" in order to take advantage of our various financial options waive the ability to file with their insurance.
All Patients:
-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.
-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.
Payments:
-We accept CareCredit (click link for the CEC-specific application), Visa, Mastercard, Discover, and Cashier’s Checks. No personal checks or cash, please.
-In certain circumstances, we may provide income- and asset-based discounts to qualified patients on a very case-specific basis to make our services more accessible to those who meet select financial criteria.
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.