UNDERSTANDING INSURANCE

DuPage Health Specialists will ask to see your insurance card at every visit. Always present your most current card.

DuPage Health Specialists requires patients to present a photo ID at their first visit.

Copays are to be paid at the time of service, either at the beginning or end of your visit. A surcharge will be assessed if DuPage Health Specialists has to bill you for a copay.

If any of the following occurs:

• you can't present your insurance card (forgot it, haven't received it yet, etc.)
• your insurance card does not have the correct primary care physician (PCP) listed.
• your eligibility can't be confirmed via our capitation list (Aetna HMO, BlueCross BlueShield HMO Illinois and HMO Blue Advantage, Unicare HMO, Humana HMO.)

you will be asked to sign a waiver. Additionally, new patients who must sign a waiver will be asked to provide two payments: any applicable co-payment plus a second payment for the balance of charges provided that day. This second payment is totally refundable once insurance is confirmed and applicable to DuPage Health Specialists. In most cases, the second payment is not deposited for three days while we await insurance coverage confirmation.

Please continue reading for information on HMO Insurance and Medicare Insurance.

UNDERSTANDING YOUR HMO INSURANCE

There are two types of HMO insurance plans - insurance plans that contract directly with physicians (Cigna HMO, United Healthcare HMO, Aetna HMO, Great West/One Health HMO) and insurance plans that contract with a physician group instead of individual physicians (BlueCross BlueShield HMO Illinois and Blue Advantage HMO, Unicare HMO, and Humana HMO.)

Plans that contract directly with physicians (Cigna HMO, United Healthcare HMO, Aetna HMO, Great West/One Health HMO) have the following requirements:

• You must choose a primary care physician (PCP) from within their network. DuPage Health Specialists' primary care physicians specialize in internal medicine and treat patients age 16 years and older.
• You must coordinate your care through your primary care physician and get referrals to specialists from this PCP. If you do not follow this requirement, the insurance plan will not pay for your care. Specialists must be in the insurance network. There are no benefits for out-of-network physicians. Your physician should always send you to an in-network hospital or facility. You and your physician can select specialists from any physician in your insurance plan network.
• Lab work should be done at the lab specified by your insurance plan. DuPage Health Specialists utilizes Quest Labs for HMO patients.
• Female enrollees have open access to in-network obstetrics-gynecology physicians for ob/gyne related problems and annual exams. No referral is ever needed for office visits to an ob/gyne physician.
  NOTE: Cigna has a new HMO called Open Access HMO that may not require you to choose a primary care physician. Please check with your insurance plan.

Plans that do not contract directly with physicians (BlueCross BlueShield HMO Illinois and Blue Advantage HMO, UniCare HMO, and Humana HMO) but instead contract with a large physician group, have the following requirements:

• You must select a primary care physician (PCP) from within their network and coordinate your care via this PCP. Your PCP selection automatically affiliates you with his/her physician group.
• Referrals from your PCP are required prior to seeing any specialist. This referral should be presented to the specialist at the time of your visit. Seeing a specialist without a referral will result in a denial of payment for charges.
• DuPage Health Specialists' Internal Medicine physicians are only affiliated with Naperville Healthcare Associates (NHCA), Site #243, and Edward Hospital. Choosing a DuPage Health Specialists' PCP means that you will be able to utilize only those specialists affiliated with Naperville Healthcare Associates. You do not have open access to all in-network physicians within your insurance plan.
• You must utilize only Edward Hospital facilities and Quest Laboratories.
• You have open access to only those obstetrics-gynecology physicians that are within the Naperville Healthcare Associates' network for annual exams and ob/gyne related problems. Ask your PCP for assistance in locating an NHCA ob/gyne physician.

DuPage Health Specialists' Obstetrical-Gynecology physicians are affiliated with both Naperville Healthcare Associates (NHCA)/Edward Hospital, site #243, and Hinsdale Physicians Healthcare/Hinsdale Hospital (HPHC), site #257. For NHCA, see instructions under internal medicine physicians.

If you are a Hinsdale Physicians Healthcare (HPHC) patient, you must utilize only Hinsdale Hospital and the specialists and primary care physicians associated with Hinsdale Physicians Healthcare. You do not have open access to all in-network physicians with your insurance plan.

Quest Laboratories should be utilized for in-office and out-of-office lab tests.

UNDERSTANDING MEDICARE

Medicare patients have an annual deductible. After this deductible is met, Medicare pays 80% of negotiated fees and the patient, or secondary insurance, pays the balance. However, Medicare does pay 100% of medically necessary lab tests.

In most cases, Medicare forwards charges to your secondary insurance. If this is not done by Medicare, our billing office will forward your claims for you - provided you have given us your secondary insurance information.

DuPage Health Specialists' physicians participate in the Medicare program. This means we accept, as payment in full, the Medicare fee schedule for covered services. If a service is not covered by Medicare, the patient is responsible for the entire DuPage Health Specialists' charge.

Highlights of Medicare coverage:

• Includes an annual exam and screening EKG only one time in the lifetime of the patient. This annual exam must occur within 6 months of initial Medicare participation. Some publications are saying that this annual exam must be the first service you receive from your physician after obtaining Medicare coverage. Please check with Medicare for clarification. This is a new benefit as of January 1, 2005.
• Other than this first annual exam, annual exams are never covered by Medicare.
• Includes a breast/pelvic exam with Pap smear for female participants every two years (730 days). If additional Pap smears are required for medical reasons, Medicare should pay for the additional Pap smears.
• Includes a prostrate exam for male patients every twelve (12) months.
• Includes annual flu vaccine.
• Does not include routine vaccinations. For example, Medicare will not pay for a tetanus shot unless it's needed as the result of an injury.
• Does not include routine/screening tests, labs, etc. Medical necessity is always required for Medicare payment.
• Whenever there is a possibility that services may not be covered by Medicare, Medicare requires that patients sign a waiver indicating they are aware that services may not be covered.

UNDERSTANDING MEDICARE WITH SECOND INSURANCE PLAN

Know whether second insurance plan is your primary (first to be billed) plan or secondary. Yes. Medicare can be a secondary plan.

If Medicare is your primary plan, you should know whether your secondary plan will cover services that Medicare does not cover, i.e., screening tests, annual exams, deductible, etc.

Medicare with PPO's as secondary insurance: Medicare does not require precertification for surgeries, MRI's, CT scans, and PET Scans. But your PPO insurance may require precertification. For the best benefits, make sure your physician's office checks with your PPO insurance plan. Also, your PPO plan may require the use of a specific lab for tests.

Medicare with HMO as secondary insurance: Again, while Medicare does not require precertification or referrals, your HMO does. For the best coverage, follow the “rules” of your HMO. Use in-network specialists. Use the HMO contracted lab (usually Quest Diagnostics). Get referrals. Make sure surgeries and extensive tests are precertified/preapproved.