After-Hours Care Appointments

Click on a question below to get answers to most of the frequently asked billing questions. If you don’t find the answer to your specific question, our billing department contact information is at the bottom of this page.

Do you have a more general question? Try our General FAQ.

General Billing Questions

Can you help me understand my bill?

Yes! Please have a look at this sample statement and the legend below. If you are having trouble viewing the information below, try this PDF Version.

sample-bill2

  1. Date of Service – This is the date the visit occurred in the office.
  2. Date of Insurance Payment – This is the date that your insurance sent information and/or payment regarding your claim to Avance Care.
  3. Services Rendered – This is a brief summary of the services that were performed during your visit. All codes are coded by the American Medical Association guidelines and are supported by provider documentation.
  4. Billed Amounts for Services Rendered – This is the amount Avance Care bills your insurance for the services rendered. This is referred to as our Usual and Customary Charges. They are the same for all insured patients and this amount is calculated based on the rates Medicare pays for services. The amount we bill your insurance does NOT determine the amount you will owe for a particular service. Your insurance company has negotiated a “in-network” discount on your behalf for the services we render. (The agreed upon discount rate is also referred to as the contract allowable and is the actual cost of the service.)
  5. Insurance Adjustment – This amount is the difference between what Avance Care has billed to your insurance company and the discount “in-network” rate agreed to with your insurance company. We are required by our contracts with in-network insurances to write off this amount which is referred to as the in-network discount or the in-network adjustment. This should match the Explanation of Benefits (EOB) you receive from your insurance company in the mail.
  6. Reason for Statement Message – This is the message that states why you are receiving a bill. This usually contains the information that the balance was put towards your responsibility as a co-payment, deductible, co-insurance, or was considered non-covered under your insurance.
  7. Balance Due – This is the amount that your insurance company has reported to Avance Care that you owe after processing your claim. This should match the Explanation of Benefits (EOB) you receive from your insurance company in the mail.
Why was my insurance billed this amount?

The amount we bill to all insurance companies is referred to as our Usual and Customary Charges. This fee is the same for all insured patients. This amount is calculated based on the rates Medicare pays for services.  The amount we bill your insurer DOES NOT determine the amount you will owe for a particular service. We have contracted with insurers we are in-network with to accept a specific amount they deem appropriate for the service. This is referred to as the contract allowable and this is the actual cost of the service. We are required by our contract with in-network insurances to write off the difference between what we billed and what they allowed. This is referred to as the network discount and is shown on your statement as the Insurance Adjustment. You receive a significant discount from our Usual and Customary Charges for choosing an in-network provider.

Can I request a change in the way my services were billed?

Unfortunately, no. Appropriate and accurate medical claims are required by federal law, and it is considered fraudulent to change billing information solely to obtain reimbursement. We therefore cannot, for example, code sick visits as well visits to avoid out of pocket charges to you, the member. We must also bill for acute or chronic condition services when they are provided during a well exam.

Can you re-file my claim?

This depends. We are able to re-file claims if they need to be re-filed to a new insurance or if they legally need an alteration in the coding. However, claims that are put towards deductibles, denied out for coordination of benefits, or pending for further information from the patient cannot be re-filed. If we re-filed these claims they will be denied as a duplicate by the insurance company as the insurance all ready has the claim in their system. In these cases the patient needs to call and ask their insurance company to reprocess the claim.

What can be done if I moved and I didn’t get the bills?

If returned mail is not received, it is assumed all mail is delivered to the intended party and Avance Care goes by the last updated information that was provided to us by the patient. If address updates are needed or necessary please contact your clinic and inform them of any updates. You can also update your demographics 24/7/365 on our secure Patient Portal. We do not take responsibility for keeping your address with Avance Care up to date.

Patients who make use of our Patient Portal will receive email notification when statements are mailed and can also review the statements on our portal to avoid issues with paper statements in the mail.

I’ve been having a rough time, can you write off my bill?

Unfortunately, we cannot write off bills. When patients visit Avance Care they have services rendered, they are financially responsible for these services regardless of insured or self-pay status.  Moreover, when a claim is processed by an insurance company, we are required by our contract with the insurer to collect the assigned patient responsibility.

We receive calls daily with patients who are having a difficult time dealing with the high cost of healthcare in the United States, which we consider to be a national crisis. We do understand and have empathy. If we are contacted before the account is turned over to our collection agency, we can work out a payment plan using CareCredit in order to help alleviate the burden of these bills. Our collection agency can also make payment plan arrangements.

I’m Self-Pay, why am I being billed? I was told it was collected in full at the time of service.

It is Avance Care policy to have all services coded by our providers before the time of check out so that you can pay in full and not receive any bills for your service. Unfotunately, our audit process occasionally identifies services that were rendered but were not coded. In these rare cases, your account maybe adjusted after you leave the clinic and a patient statement will be forwarded for the remaining charges.

I have insurance, why did you take a $100 deposit at the time of service?

We collect a $100 deposit at the time of service for patients who have a high deductible insurance plan and have not met their deductible. High deductible insurance plans apply office visit charges to the patient’s deductible until it has been met, so we ask for a $100 deposit at the time of service to help cover the cost of the deductible that will be applied by the insurance company.

Once the claim processes, we will issue a statement for any remaining balance that insurance has put towards the patient’s deductible. If less than $100 was applied to the patient’s deductible, we will issue a prompt refund.

Deductibles

What is my deductible and why are you charging me this?

If you have a high deductible insurance plan, your contract with your insurer states the deductible must be met before the insurer will issue any payments for medical office visits on your behalf.  This is similar to automotive or homeowner’s insurance deductibles. For example, if you have a $1,500 deductible on a high deductible insurance plan, you must pay that amount before expenses are covered by your insurance. In this example, each time you come to the doctor your visit will be put towards your deductible until you have paid $1,500 out of pocket.

We do recommend that you contact your insurance company as they will be able to explain your specific plan in detail and how much of your deductible you have met to date.  Even co-pay insurance policies may have a deductible that applies to specific services such as labs or diagnostic imaging. Your insurance company can advise you as to what services have a deductible and how much deductible you have remaining on your plan. In many cases, your insurance may have an associated Health Savings Account (HSA) to help you pay for deductibles, and your insurer or your employer can advise you as to how you can access the funds in this account.

What is my deductible and why are you charging me this?

If you have a high deductible insurance plan, your contract with your insurer states the deductible must be met before the insurer will issue any payments for medical office visits on your behalf.  This is similar to automotive or homeowner’s insurance deductibles. For example, if you have a $1,500 deductible on a high deductible insurance plan, you must pay that amount before expenses are covered by your insurance. In this example, each time you come to the doctor your visit will be put towards your deductible until you have paid $1,500 out of pocket.

We do recommend that you contact your insurance company as they will be able to explain your specific plan in detail and how much of your deductible you have met to date.  Even co-pay insurance policies may have a deductible that applies to specific services such as labs or diagnostic imaging. Your insurance company can advise you as to what services have a deductible and how much deductible you have remaining on your plan. In many cases, your insurance may have an associated Health Savings Account (HSA) to help you pay for deductibles, and your insurer or your employer can advise you as to how you can access the funds in this account.

Can you adjust my deductible to Self-Pay fees?

We cannot make adjustments to fees after a claim is filed with your insurance. When you present your insurance card, and we are in-network with that insurance, we are required by our contract with the insurer to file a claim on your behalf.

It is your right, under the HIPAA Omnibus Final Rule published in the Federal Register on January 25, 2013, to pay in full at the time of service and request that we do not file a claim with your insurer.  In these cases, we will honor the self pay fee schedule. You must complete our service specific waiver form at each visit that you do not want billed to your insurance and pay in full at the time of service.

Late Fee

Why am I being billed a late fee?

A late fee is an administrative charge added to your bill once we have sent out multiple statements to the patient and have not received payment in full. When the late fee is added, we have sent the patient at least one statements over the last two months with no full payment. We charge this administrative fee to recoup the expenses we incur in generating and handling these additional statements.

If you are having trouble paying your bill, we urge you to contact the office and arrange a payment plan to avoid statement or collection agency fees.

Can this late fee be waived?

We will not waive the late fee because we have already incurred the expense of generating and sending multiple statements. You can avoid the fees by either paying your balance or arranging a payment plan with CareCredit prior to the sending of multiple statements.

We do understand that sometimes life gets in the way. Our late fee gives patients a final opportunity to pay off the balance or arrange a payment plan with CareCredit before it is turned over to our collection agency and incurs additional collection agency fees.

Co-pays and/or Deductibles with Annual Physical Exams

Why do I have a co-pay and/or deductible with my yearly physical? Isn’t it suppose to be free?

Most insurance plans do cover one preventive physical per year at 100% as required by the Affordable Care Act, however a preventive exam typically means that you are going into the appointment with no medical concerns or problems. Insurers will apply a co-pay or deductible for any services that are outside of preventive care such as counseling or treatment of acute or chronic illnesses, similar to the way they would process your claim had you presented specifically for an acute or chronic medical problem.

For example, if you go to your physical and also want to discuss your low vitamin D, your diabetes, or your stuffy nose, this is considered a completely separate service that generates its own fees. We do recommend that you call your insurance company and speak to one of their representatives who can outline what is and isn’t considered preventive under your plan. Please refer to our Insurance Coverage of Physical Exams form signed before each physical. Please also refer to our Patient Policies page where we have outlined relevant information in red.  We have placed a sign explaining this common insurance issue in each exam room.

Are you saying I can’t discuss concerns with my doctor during my annual physical?

No, we are not saying that. Our providers are happy to discuss any concerns you may have at any time, but specifically for the yearly preventive exam, treatment of conditions outside of preventive medicine is considered a separate service by your insurer, and will incur separate co-pay/deductible/co-insurance charges. Covered preventive services include:

  • Screenings for common or preventable diseases
  • Complete physical examination, including pap smear testing for women
  • Review of immunizations and administration of any CDC recommended vaccines
  • Counseling on healthy living choices, normal development, and recommendations for proper diet and exercise.
  • Diagnostic testing deemed appropriate by the United States Preventive Services Task Force (USPSTF). Examples include pap smear, colonoscopy, and mammogram.

Again, we are happy to work with you to resolve any medical issue or concern, but you should be aware of how insurance coverage for acute or chronic condition management is different than the insurance coverage for preventive services that is mandated by the Affordable Care Act.

After Hours / Weekend Service Fee

What is this After-hours/Weekend fee and why is this billed?

This fee is billed to insurance companies in order to reimburse Avance Care for the higher cost of remaining open and available to you 72 hours per week. Avance Care uses an Extended Hours Service code when submitting insurance claims on your behalf for services that occur after 6pm on weekdays, or on the weekends. The fee for this service code is up to $50. This fee is added to the baseline charges for your visit. Most insurance companies recognize this charge and will provide full or partial payment. You may be responsible for only the allowable portion of this charge in the event that your insurance assigns this towards your deductible or co-insurance.

With Urgent Care and ER co-payments typically set at a much higher rate than primary care co-payments, Avance Care is typically a much more affordable option for after hours or weekend care, even when separate deductible or co-insurance is applied to the after hours code.

Why was I not told about this After Hours/Weekend fee when scheduling my appointment?

More often than not, this charge is allowed and paid by the insurance company and the patient enjoys after hours care for a primary care co-pay as opposed to more expensive urgent care and ER co-pays.

When your appointment is made, we do not know if this fee will be covered, written off, or applied towards the patient’s responsibility by their insurance. We only become aware of this information when the claim is processed.

We do try our best to ensure patients are aware of this in case it does fall to their responsibility.

We have placed After Hours / Weekend fee information:

  • on two signs in the lobby both at the check-in and check-out desks
  • in the email message web-enabled patients receive when booking their appointment
  • in the email message web-enabled patients receive the day before their appointment
  • in the email message web-enabled patients receive when a new statement is put on their Portal
  • on the Disclosures and Consents form signed by all patients
  • on our website under Patient Policies outlined in red
Can this After-Hours/ Weekend fee be waived?

No, this is not something we have the ability to change, waive, or write off. Your insurance policy is a contract between you and your insurance company and we are not responsible for deciding how the claim will process or how much money will be placed towards your deductible. You have agreed, in your contract with the insurer, that amounts applied to your deductible are your financial responsibility.

Furthermore, our contract with your insurer requires that we collect deductibles, coinsurance, and co-payments that are applied to patient responsibility when the claim is processed.

Co-Pays

What is my co-pay and why are you charging me this?

As part of the contract you have with your insurance, some plans require that the patient pay a set amount for each visit. This may or may not include any tests or procedures associated with the visit. Some plans require a co-pay for the office visit and then have a separate deductible or co-insurance for labs and/or procedures.

Some insurance policies may also have a combination of deductibles, co-insurance, and co-pays. For example, a policy may require a subscriber to meet $1,500 deductible, after which the subscriber is required to pay 10% co-insurance. We do recommend that you contact your insurance company as they will be able to explain your specific plan in detail.

Specialty Co-pays

Why am I being billed a specialist co-pay?

Typically, patients are billed a specialist co-pay by their insurance for one of two reasons.

  1. If a patient has seen a nurse practitioner, some out of state insurance plans consider all Nurse Practitioners to be specialists and require a specialist co-pay for these visits. Unfortunately, we cannot resolve this issue as it is a plan design mandated by the employer providing the health insurance. To resolve this issue, patients should call their insurance company and inform them they were seen at a primary care and not a specialist’s office. Many patients are successful in having their claim reprocessed to resolve this issue.
  2. If a patient is required to specify a PCP (Primary Care Provider) by their insurance company, and a provider not affiliated with Avance Care is specified as the patient’s PCP with their insurance at the time of service at Avance Care, this may generate a specialist’s co-pay even though we are a primary care provider. Some insurance plans will only allow you to pay your primary care co-pay when seeing the provider you have designated to your insurance is your primary care doctor. If you would like to have your primary care co-pay when coming to Avance Care, please contact your insurance company and designate one of our providers as your PCP.

Co-Insurance

What is my co-insurance and why am I being billed this?

Some insurance plans have a co-insurance requirement meaning that the patient and the insurance company each pay a certain percent of the visit. If you have further questions we urge you to contact your insurance company for full details on your insurance plan.

Can you waive my co-insurance?

No, this is not something we have the ability to change, waive, or write off. Your insurance policy is a contract between you and your insurance company and we are not responsible for deciding how the claim will process or how much money will be placed towards your deductible. You have agreed, in your contract with the insurer, that amounts applied to your deductible are your financial responsibility.

Furthermore, our contract with your insurer requires that we collect deductibles, coinsurance, and co-payments that are applied to patient responsibility when the claim is processed.

Credit Card Authorization

Why Avance Care obtains credit card authorization and how it works?

Scheduled Payment Will Make Your Life Easier:

  • It’s convenient (saving you time and postage)
  • It’s worry free. Your payment is always on time (even if you’re out of town), eliminating late charges and the possibility of collection agency reporting
  • We gladly accept Visa and Master cards for this process to make it easy
  • We currently don’t accept debit or HSA cards

Avance Care, P.A. has partnered with the credit card industry’s leading PCI compliant payment gateway service. Authorize Net (CyberSource Corporation, a wholly owned subsidiary of Visa.) Payment authorizations are processed through a secured, encrypted channel and securely stored on Authorize.Net’s system using advanced tokenization security.

As added security, Avance Care, P.A. does not store your credit card information on its electronic systems.

Authorized account balance payments will be automatically charged to your Visa or MasterCard only after being informed via a mailed patient statement.

Here’s How Scheduled Payment Works:

  • You authorize Avance Care, P.A. to charge your credit card for any “patient” balance after the claim(s) have been created (for self-pay patients) or processed through your insurance provider.
  • The authorization is to charge your credit card for fees not collected at the time of the service or not covered by insurance and/or deductible, co-pay, and co-insurance portions of your medical services provided.
  • Your credit card will only be charged after 30 days from the initial statement mailing alerting you of your balance with us. Your credit card will not be charged if payment is made within 30 days of mailing the initial statement.
  • A receipt for the charge will be emailed to you to the email address you provide on this authorization
How do I de-authorize a credit card authorization?

To de-authorize a credit card, please visit the Credit Card De-Authorization Page.

Claim Denial: Coordination of Benefits

My claim was denied for Coordination of Benefits (COB). What does this mean?

When a claim is denied for this reason it is because your insurance believes that you have another health insurance policy that would have paid for the services. This is very common when you have changed health insurance within the last year. Some insurers require that you update coordination of benefits information every year. Your insurance will not pay the claim until you contact them and update your coordination of benefits information. They will not accept coordination of benefits information from us.

To resolve this, please contact your insurance company and speak to a representative about your coordination of benefits and specifically ask them to reprocess your claim. You may have also received a questionnaire in the mail that you can complete to update your coordination of benefits information. You must update your information and ask them to reprocess your claim before they will process this claim and issue payment on your behalf. It is important to take immediate action to resolve these situations to avoid additional statement or collection fees.

I updated my Coordination of Benefits with my insurance, can you re-file my claim?

Claims that are denied out for coordination of benefits information cannot be re-filed by Avance Care. If we re-file these claims they will be denied as a duplicate by the insurance company as the insurance already has the claim in their system. In these cases the patient needs to call and ensure their coordination of benefits information is up to date and also ask their insurance company to reprocess the claim.

Claim Denial: Pending Further Information
/ Pre-existing Information

My claim was denied pending for further information. What does this mean?

When a claim is denied or is pending for further information for a pre-existing condition the insurance company is waiting on information from the pre-existing condition questionnaire that was sent in the mail to the patient. If you have your claim denied for this reason but have not received a questionnaire please contact your insurance company to resolve the issue.

Claim Denial: No Coverage for This Date of Service

My claim was denied stating that I did not have coverage for my visit. How can this be resolved?

When health insurance coverage is not in force as expected, the most successful solution is for the patient to call their insurance company and speak with a representative regarding this denial. Since the contract is between you and your insurance company Avance Care cannot address this situation.

If you did have coverage at the time of your visit, please address this with your insurance company and ask them to reprocess the claim.

If you had insurance coverage through a different insurance company please contact Avance Care to provide your new insurance information. We may or may not be able to file the claim on your behalf based on the timely filing guidelines your insurance company has set in regards to claims submissions. If we are unable to file the claim due to timely filing, the patient will be responsible for the full amount. Please bring the most recent copy of your insurance card to each visit to avoid this issue.

Claim Denial: Maximum Benefits Exhausted

I have a balance stating that maximum benefits have been exhausted. What does this mean?

Maximum benefits is a restriction your insurance company places on the amount of money they will pay for a particular service during the policy year. Once your insurance company has paid up to their maximum for that particular service, they will deny claims in the same policy year for that service because you have exhausted your maximum benefit. Services rendered that exceed the insurer’s maximum benefit for the policy year are considered patient responsibility.

Contacting our Billing Department

I still have questions. How do I contact your billing department?

There are 3 easy ways to contact our billing department.

  1. You can give us a call at (919) 237-1337. If we do not pick up, we are likely helping another patient. Please leave a message and we will promptly return your call.
  2. You can use the Contact Us section of this website.
  3. You can LiveChat with a billing support person during business hours.
  4. For sensitive matters, you may prefer to contact us via the secure email service on our Patient Portal.
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