Wilson Family Medicine Information Regarding Insurance Plans and Coverage for Health Maintenance

The providers and staff at Wilson Family Medicine are committed to providing the best healthcare to the patients we care for. We are dedicated to the concept of preventative healthcare and we strive to keep you healthy. Routine physical examinations and blood tests, as well as certain other screening examinations such as pap smears, mammograms, and other diagnostic procedures are recommended at certain ages and intervals in order to detect treatable diseases before they become symptomatic. However, some insurance plans do not cover some or all of the recommended screening examinations unless there is an existing diagnosis or problem.

Typically, health maintenance organizations (HMOs) will pay for routine physicals and screening examinations for preventative purposes. Indemnity and government insurance plans usually do not cover routine physicals and blood work, though some may under certain conditions or at set intervals. It is your responsibility to contact your insurance company to determine whether routine preventative services will be covered by your health insurance.

Your health insurance is a contract between you and your insurance company, and specifics may vary from plan to plan, even within the same company. That contract should specify which medical services will and will not be covered by your insurance company. Wilson Family Medicine will file claims for some insurance plans as a courtesy, and for some we are preferred providers, which means that we will accept their allowable rate for their covered services. However, if a service is provided that is not covered by your plan, payment for that service is your responsibility. Wilson Family Medicine will make every reasonable effort to collect payment from your insurance company. Claims will be filed electronically in a timely fashion. Once a claim is filed, the insurance company will submit an explanation of benefits (EOB) to both the provider of services (such as WFM or the laboratory) and to the patient. If the EOB indicates the service provided was a non-covered service, your deductible had not been met at the time of filing, or if the service is partially paid, the balance (of the ENTIRE charge if we are not preferred providers, or the service is non-covered, or of the ALLOWABLE charge of covered services when we are preferred providers) will then be transferred to patient responsibility. You will then receive a statement from our office for payment. Also, if your insurance company does not respond to the claim within 90 days, the balance for services rendered will be transferred to you, the patient.

Similarly, blood testing and other screening diagnostic tests ordered by your provider but performed outside of WFM may not be covered by your insurance company. In these cases, you will receive a bill from the diagnostic center or other provider of services. You may also receive bills from these diagnostic centers for co-insurance, which may be a copay or percentage, or for unmet deductibles.

In short, we strive to help you stay healthy and firmly believe in performing the recommended screening examinations to attain that goal, even if it is not covered by your insurance company. If you have any further questions about what is and is not covered by your insurance company, you may contact your plan’s member services representative.

Sincerely yours in health,

Les Wilson, MD
Vicki Erwin-Wilson, MD
Melanie Spells, ARNP
WFM staff
www.wilsonfamilymedicine.com