AGH - Hospital Billing FAQ

What is the difference between and HMO and PPO?
What is a third-party administrator? 
How will my bill be submitted?
Why do I have to pay when I have insurance?
What will I have to pay if AGH is non-participating with my insurance?
My insurance is non-par. Will you sign an agreement to accept this insurance?
What does a contractual adjustment mean? 
How much of the bill will my insurance company cover? 
Why can’t the AGH reception and clinical staff tell me what my insurance will cover?
I have insurance, so why am I receiving a bill? 
What do I do if I disagree with how much the insurance paid? 
Can you re-bill my insurance if they did not pay? 
What does coordination of benefits mean? 
Can you bill my child’s other parent’s insurance for the visit? 
Why can’t I receive account information about other family members (ex. Adult child, parent, spouse).
Why am I getting my bill months after I was treated? 
You billed me for a doctor I did not see! Why? 
Can I pay my bill online? 
Can I set up a payment plan? 
What if I can't afford my bill?
Financial help options.

What is the difference between and HMO and PPO?
Most of the time HMOs tend to be group plans rather than individual plans. An HMO requires that you only see its doctors, and that you get a referral from your primary care physician before you see a specialist. They may have central medical offices or clinics or it may consist of a network of individual practices.
Preferred Provider Organization (PPO). PPOs have made arrangements for lower fees with a network of health care providers. PPOs give their policyholders a financial incentive to stay within that network. For example, a visit to an in-network doctor might mean you'd have a $10 co-pay. If you wanted to see an out-of-network doctor, you'd have to pay the entire bill up front and then submit the bill to your insurance company for an 80 percent reimbursement. In addition, you might have to pay a deductible if you choose to go outside the network, or pay the difference between what the in-network and out-of-network doctors charge. Preventive care services may not be covered under a PPO.
back


What is a third-party administrator?

Third Party Administrator (TPA) is an organization that processes insurance claims. The TPA is not the insurer; they do not pay the claim.
For example, an employer may choose to contract with a TPA for administration of the claims processing for employees and a TPA may administer many aspects of a self- funded health care plan. An insurance company may also use a TPA to manage its claims processing, provider networks, utilization review, or membership functions.
back


How will my bill be submitted?

The claim is submitted to the insurance and reimbursement is sent directly to the provider if AGH participates with your insurance.
Participating with the insurance means that you re-assign benefits to the provider, and the provider will accept the allowed amount by your insurance.
back


Why do I have to pay when I have insurance?

If you are covered by a participating insurance, we are contractually obligated to collect any co-pay, co-insurance or deductible from you. Prior to your visit, we verify your insurance coverage and the amount you will be responsible to pay at the time of service.
Medicare patients will pay their co-insurance at the time of service if they do not have a secondary insurance. Patients with a medigap coverage (or insurance that covers their deductibles and/or co-insurance) will not pay at the time of service.
back

What will I have to pay if AGH is non-participating with my insurance?

If you are covered by an insurance that is non-participating with AGH, payment will be expected on the date of service. The patient accounting office will provide you with a itemized bill so that you can submit it to your insurance.
Non-Participating with the insurance means that you do not assign benefits to the provider, and the provider does not accept a discounted reimbursement.
The insurance will reimburse you directly.
back

My insurance is non-par. Will you sign an agreement to accept this insurance?

You can contact your insurance company and ask if they contract with providers in this area. Letters of interest to participate should be submitted to:

AGH, 9733 Healthway Drive, Berlin, Md 21811
Attn: Payer Relations Committee
back


What does a contractual adjustment mean?

This is the difference between the amount that the physician charges and what the contractual agreement is with your insurance. The patient is not responsible for this portion of the fee if it is a covered service.
back

How much of the bill will my insurance company cover?

Questions regarding insurance coverage and benefits should be directed to your employer or insurance company.
back

Why can’t the AGH reception and clinical staff tell me what my insurance will cover?

Health insurance is important to all of us, but can be difficult to understand. The benefits, rules, and restrictions are determined by the terms of your policy, as well as the contracts AGH has with the various insurance carriers. These questions, and others, that are specific to the coverage of your own insurance policy should first be directed to your insurance provider. Insurance contact information will be located on your insurance card, the insurance website or in your policy manual.
back


I have insurance, so why am I receiving a bill?

Insurances rarely pay 100% of medical services. The benefits, rules, and restrictions are determined by the terms of your policy.
back

What do I do if I disagree with how much the insurance paid?

If you disagree with the amount the insurance paid for a claim, contact the insurance company directly. If the insurance finds that an error was made on their part, make a note of the information and with whom you spoke. If the insurance states that the bill was paid correctly and you still disagree, ask the insurance company how to file an appeal.
back

Can you re-bill my insurance if they did not pay?

We can re-bill a claim within 180 days from the date of service for valid reasons such as data entry errors, inaccurate patient or insurance information.

Other reasons that need a resubmission is when the insurance company processes the claim incorrectly by paying “out of network” benefits if we participate with your insurance. We cannot re-bill a claim if the documentation in the medical record does not support the diagnoses or procedure code that has been submitted.
back

Why can’t I receive account information about other family members (ex. Adult child, parent, spouse).

Due to HIPPA (Health Insurance Portability and Accountability Act) we legally are not allowed to disclose any information to anyone other than the patient if they are over the age of 18 unless permission has been granted to us by the patient.


What does coordination of benefits mean?

Coordination of benefits (COB) is used to establish the order in which health insurance plans pay claims when a patient has more than one insurance. We bill your primary insurance, then your secondary insurance. When health care benefits are coordinated, the insurance companies share the cost without overpaying.
back

Can you bill my child’s other parent's insurance for the visit?

If a patient is under the age of 18, the parent presenting the child for examination is considered the parent responsible for the bill.
back

Why am I getting my bill months after I was treated?

Some insurance plans take up to 90 days or more to pay a claim. The patient is not sent a statement until your insurance has processed your claim.
back

You billed me for a doctor I did not see! Why? 
• Some insurances require when a patient sees a nurse practitioner or certified physician assistant that the claim is submitted under the supervising physician's name.
• If you had surgery you may not recall or know the anesthesiologist’s name.
• A bill may be submitted for the “technical” portion of the services (such as x-rays, EKGs). The bill will have the name of the physician who oversees the facility or has read/reviewed your test or x-ray.
back

Can I pay my bill online?

Yes, you may pay online. Click here to fill out the form. 
Select the correct type of payment from the drop down screen, physician visit fee or hospital charge.
back


Can I set up a payment plan?
In some circumstances a payment plan can be arranged prior to services. Please call 410-641-9101 for more information. More information on Financial Assistance. 
back