INSURANCE INFORMATION
At Premier Orthopaedics, we are committed to providing accessible and comprehensive orthopaedic care to our patients. We understand that navigating insurance coverage can be complex, so we strive to make the process as transparent and seamless as possible. Here’s what you need to know about insurance coverage and accessing care at our practice:
We are in network with nearly all major insurance carriers.
To verify if we are in-network with your plan, please complete the form below. Someone from our office will review your benefits and call you back as soon as possible.
At Premier Orthopaedics, we accept nearly all major insurance carriers to ensure that our patients have access to the care they need. Whether you are covered by private commercial insurance, Medicare, Medicaid (Horizon NJ Health, Amerigroup) Tricare (which supports veterans and their families), Workers Compensation, No-Fault insurance, or other insurance plans, we are here to assist you in accessing the orthopaedic services you require.
Understanding Insurance Terminology:
Co-Pays:
A co-pay is a fixed amount that you are required to pay out of pocket for certain medical services, such as doctor visits or prescription medications. The amount of your co-pay may vary depending on your insurance plan and the specific services rendered.
Deductibles:
A deductible is the amount of money you must pay out of pocket for covered medical services before your insurance coverage begins to pay. Once you reach your deductible amount, your insurance plan will typically cover a percentage of the remaining costs (see co-insurance).
Co-Insurance:
Co-insurance is the percentage of the total cost of a covered medical service that you are responsible for paying after you have met your deductible. For example, if your insurance plan has a 20% co-insurance requirement, you would be responsible for paying 20% of the covered medical expenses, while your insurance plan would cover the remaining 80%.
Out-of-Network Coverage:
Some insurance plans may offer out-of-network coverage, which allows you to receive care from providers who are not part of your insurance plan’s network. However, out-of-network services may be subject to higher co-pays, deductibles, or co-insurance rates compared to in-network services.
Navigating Insurance Coverage:
Understanding your insurance coverage and benefits is essential for making informed decisions about your healthcare. Before scheduling an appointment or undergoing treatment, we recommend contacting your insurance provider to verify coverage, including any co-pays, deductibles, or co-insurance requirements. Our knowledgeable staff is also available to assist you in navigating insurance-related inquiries and ensuring that you have access to the care you need.
At Premier Orthopaedics, we are dedicated to providing high-quality orthopaedic care to all of our patients, regardless of their insurance coverage. If you have any questions or concerns about insurance billing, coverage, or payment options, please don’t hesitate to reach out to our friendly staff for assistance. We are here to support you every step of the way on your journey to improved orthopaedic health and wellness.
Your Partners In Managing Insurance Concerns
We understand the importance of having the necessary medical coverage, which is why we proudly accept Medicare and Medicaid.
We recognize that insurance terms and policies can be difficult to decipher, and we’re committed to making this process as straightforward as possible for you. If you find yourself unsure about whether our services are covered under your insurance plan, don’t hesitate to reach out to one of our knowledgeable insurance specialists. They’ll be more than happy to provide clarity and guidance, ensuring you have the information you need to make informed decisions about your healthcare. Your peace of mind is our priority, and we’re dedicated to helping you navigate the intricacies of insurance with confidence.
Understanding Insurance Requirements for Orthopaedic Care
At Premier Orthopaedics & Sports Medicine, we understand that navigating insurance approvals can be complex and sometimes frustrating. Our goal is to guide you through the process and help you understand the requirements set by major insurance carriers before we can proceed with advanced imaging studies, injections, or surgery. While we strive to deliver timely and effective care, it’s essential to recognize that insurance protocols play a significant role in determining the approval of certain treatments.
Typical Insurance Protocols and Requirements
1. Initial Assessment and Conservative Treatment Mandates Most insurance carriers, including Horizon Blue Cross Blue Shield (BCBS), UnitedHealthcare, Cigna, and Medicare, require patients to undergo conservative treatment options before authorizing more invasive procedures or advanced diagnostics. Common initial requirements include:
- Physical Therapy (PT): Typically, a minimum of 4 to 8 weeks of documented physical therapy sessions are required before authorizing advanced imaging or interventional treatments.
- Medication Management: Patients may need to demonstrate that they have tried and failed with medication management, including NSAIDs or other non-opioid pain relief methods.
- Lifestyle Modifications: Documentation of patient compliance with lifestyle changes, such as weight management and ergonomic adjustments, is often required as part of conservative treatment.
2. Diagnostic Imaging Approval Process Before proceeding with imaging studies like MRIs or CT scans, insurance carriers may enforce the following guidelines:
- Pre-Authorization: Most carriers, including UnitedHealthcare and Cigna, require prior authorization to justify the medical necessity of imaging studies. This often involves submitting clinical notes detailing the patient’s symptoms, history, and findings from physical exams.
- Conservative Treatment Documentation: Insurance providers may deny advanced imaging if there is insufficient evidence that conservative treatments have been attempted or documented.
- Criteria for Approval: For example, Medicare may approve an MRI for persistent pain lasting more than 6 weeks if accompanied by red flags like neurological deficits or suspicion of serious conditions (e.g., infection or malignancy).
3. Injection and Pain Management Protocols When it comes to injections such as corticosteroid injections, epidural steroid injections (ESIs), or nerve blocks, insurance carriers often require:
- Trial and Documentation of Non-Invasive Methods: Before approving injection therapy, insurers like Horizon BCBS often mandate a trial period with non-invasive pain management, including physical therapy and oral medications.
- Specialist Evaluation: Approval may require an evaluation by a specialist (e.g., a pain management physician or orthopaedic surgeon) who confirms the medical necessity based on patient history and physical findings.
- Pre-Authorization and Medical Necessity: Detailed pre-authorization is essential, with documentation including previous treatments, patient response, and imaging results to support the request.
4. Surgery Approval Requirements Surgical interventions, such as joint replacements, rotator cuff repairs, or spinal surgeries, are subject to strict protocols:
- Failure of Conservative Treatments: Most insurers, including Cigna and Medicare, require documented failure of non-surgical treatments over a defined period (typically 3 to 6 months) before considering surgery. This includes physical therapy, medication trials, and sometimes injections.
- Second Opinions: Some carriers may request a second opinion from an independent specialist to confirm the need for surgery.
- Comprehensive Medical Review: Insurance carriers may require comprehensive documentation, including imaging studies, patient progress notes, and reports indicating significant functional impairment that affects daily living or work.
Why Insurance Approvals Can Be Delayed or Denied
1. Medical Necessity Criteria Insurance companies evaluate the necessity of a procedure or treatment based on established medical guidelines. If a treatment is not deemed medically necessary according to their criteria, it may be denied. Common reasons for denial include:
- Insufficient Documentation: Lack of detailed medical records showing prior treatments and patient outcomes.
- Non-Compliance with Guidelines: If conservative treatments were not adequately documented or attempted.
- Deviation from Protocols: Requesting advanced treatments too early in the care process without fulfilling pre-requisites.
2. Appeals and Peer Reviews If an insurance denial occurs, our practice will assist in the appeal process, which may involve:
- Peer-to-Peer Review: A discussion between our specialists and the insurance carrier’s medical director to justify the treatment based on clinical evidence.
- Submission of Additional Evidence: Providing supplementary clinical data, patient history, and relevant research to support the request.
Patient Understanding and Expectations
1. It’s Not Always Our Decision Patients should understand that while we advocate for their best care, the approval of treatments ultimately depends on meeting the specific protocols set by their insurance carrier. Our team works diligently to submit comprehensive documentation and adhere to these guidelines to facilitate approvals.
2. Why Insurance Protocols Exist Insurance carriers implement these protocols to:
- Ensure that treatments are medically necessary and supported by clinical evidence.
- Control healthcare costs by avoiding premature or unnecessary procedures.
- Promote initial conservative treatments, which can be effective for many conditions.
3. How We Support You At Premier Orthopaedics & Sports Medicine, we:
- Guide You Through the Process: Educate patients on the necessary steps and expected timelines for obtaining treatment approval.
- Ensure Comprehensive Documentation: Submit detailed patient records and treatment histories to meet carrier requirements.
- Advocate on Your Behalf: Participate in peer reviews and appeals to support the approval of recommended treatments.
Insurance Carrier-Specific Highlights
Horizon BCBS:
- Pre-authorization for Imaging: Often requires documented evidence of conservative management and clear indications for advanced imaging.
- Injections and Surgery: Typically mandates a 6-12 week period of non-surgical treatment before considering surgical options.
UnitedHealthcare:
- Imaging and Procedure Protocols: Emphasizes medical necessity with thorough documentation of patient symptoms and physical exam findings.
- Surgical Review Process: May include a requirement for physical therapy completion within a 12-week window prior to approving surgical procedures.
Cigna:
- Conservative Treatment Documentation: Insists on comprehensive notes showing treatment adherence and response over at least 3 months.
- Approvals for Pain Management: Often requires a specialist evaluation and submission of prior imaging and treatment response details.
Medicare:
- Guideline-Driven: Follows strict, evidence-based guidelines for all procedures and approvals, focusing on medical necessity and patient impact.
FAQs on Insurance Requirements
Q1: Why was my MRI or surgery request denied? Denials often occur due to insufficient documentation or failure to meet the conservative treatment requirements set by your insurance carrier.
Q2: What steps can I take if my treatment is denied? We can initiate an appeal process, providing further documentation and conducting peer-to-peer reviews to support your treatment.
Q3: How long does the approval process typically take? Approval timelines vary by carrier but can range from a few days to several weeks. Our staff will keep you updated throughout the process.
Contact Us for Assistance
For questions or support related to insurance requirements for your care, or visit our office to discuss your case.
For any questions regarding Insurance Coverage, please use the form below to contact us, and a member of our staff will contact you.