Partnership for Health

http://www.oldtowndoc.com/

Dr. Grimshaw’s insurance relationship and billing/fee policies may be different from what you are used to seeing at a doctor’s office, so we wanted to take a moment to discuss this with you, as well as give you helpful tips for talking with your insurance company about reimbursement.

As you may or may not know, Dr. Grimshaw does not hold any contracts with insurance companies, including Medicare and Medicaid. What that means for you as a patient is that the fees for each visit are due on the date of service. Some offices stop there, and leave the option of seeking insurance reimbursement up to the patient, which can be time-consuming and confusing. At our office, as a courtesy to our patients, Dr. Grimshaw employs a very knowledgeable and experienced biller who will take care of billing your insurance for your visits so that you don’t have to. From there, if you are entitled to a reimbursement for services, your insurance company will issue a check directly to you for that amount.

Reimbursements are subject to the individual benefits of your insurance plan, as well as the amount of your deductibles. Because of Dr. Grimshaw’s status as a non-participating provider, the fees from his visits generally go towards an out-of-network deductible first, if your plan includes one. Once you have exceeded that out-of-network deductible, then you can expect to have reimbursement checks sent to you. Every insurance provider is different, though, so if you are unsure of your benefits, we suggest to all of our patients that they contact their insurance company directly to find out. If you are interested, we can provide you with the procedure codes with which we would bill your insurance so you can get a more accurate idea from your insurance company regarding reimbursement.

The exception to this rule is Medicare. Dr. Grimshaw is considered an “opted-out” provider, which means that he no longer has a relationship with them. According to the rules put forth by the Centers of Medicare and Medicaid Services, providers who have opted-out are not able to send in claims for reimbursement on behalf of their patients, nor are the patients able to send claims in themselves. Patients who have a secondary insurance provider, however, are able to submit the claims from their visits to that secondary insurance for possible reimbursement from them. As with commercial insurances, benefits and reimbursement can vary quite a bit. We encourage those who are interested in turning claims in to a secondary insurance to call their insurance to enquire about possible reimbursement. We would be happy to provide you with more information and billing codes if you are interested in this.

If you are interested in checking with your insurance company about reimbursement for Dr. Grimshaw’s services, below we will list the insurance procedure codes used in normal appointments:

99205 – Comprehensive New Patient Office Visit Code
99214 – Extended Established Patient Office Visit Code (this would be used for follow-ups)
98926 – Osteopathic Manipulation, 3-4 Areas (this number will vary depending on how many areas of the body
he treats per visit)

Each visit is a combination of an office visit and osteopathic manipulation codes

For an adult, the fees for the initial visit range from $320 to $400 for a 90 to 120 minute appointment. Follow ups drop down to between $235 and $275 for 45 to 60 minute appointments.

The fees for the initial visit for children/babies range from $225 to $300 for a 60 to 90 minute appointment, and from $150 to $195 for 45 to 60 minute follow ups.

If you still have questions after reading this, please let us know! We’d love to help answer any questions you may have. http://www.oldtowndoc.com/