Our Billing Process
Thank you for choosing Our Billing Process
Not sure about what your insurance covers?
Cleveland Clinic for your Having a hard time figuring out your physician
and hospital bill? Cleveland Clinic’s Patient
healthcare needs. We Financial Services (PFS) team has prepared
this pamphlet to answer questions you
appreciate the confidence may have about insurance, billing, financial
assistance and related topics.
you have placed in us. If you need more information, we are here
to help. Please call PFS at 216.445.6249
or toll-free at 866.621.6385.
Our website also provides information on
This brochure has been prepared to answer
insurance and billing. See us at http://
many common questions that patients
have about insurance, billing and financial
assistance for our services. Please let us
know if we can answer any additional
questions to help make the financial side of Insurance
your experience with us as easy as possible,
1. When do I make a co-payment or
so you can focus on your health and wellness.
Most insurance companies require patients
to pay a portion of their doctor’s visit
or hospitalization costs. This is called a
co-payment or a deductible, and these
payments are generally made before your
appointment, procedure or admission. If
these payments are not made, we may have
to reschedule your appointment. If you have
questions when you come in for care, the
financial counselor in that area can help.
2. I have surgery scheduled soon.
How do I know it will be covered?
Many insurance plans require prior
authorization (sometimes called pre-
certification) for services such as inpatient 4. How would I be covered if I’m placed
surgery. When Cleveland Clinic schedules under observation status?
these services, we check with the patient’s When your physician places you under
insurance company. If they do not approve observation status, this means our clinical
the service, we notify the patient before staff will closely monitor you for the next
the service takes place. Patients who several hours. Your observation period
decide to proceed with the service are will be used to determine if you can be
responsible for payment. sent home or need to be admitted as a
If you are scheduled for surgery at any hospital inpatient. Observation status
Cleveland Clinic inpatient or outpatient includes medically reasonable and
surgery location, you can also view a free necessary services such as ongoing short
online video that can help you figure out term treatments, assessments and close
what your insurance covers, including monitoring, tests and certain procedures.
referrals, pre-certifications and out-of- Observation status for 24-48 hours is
pocket costs. generally covered by healthcare plans.
If it extends beyond that, you may be
To access this video, please visit: financially liable for the additional care.
http://my.clevelandclinic.org/patients- Insurance companies require that we bill
visitors/billing-insurance/default.aspx. all observation status care as outpatient
services. If you have questions about how
3. My primary care physician wants me your healthcare plan treats observation
to see a specialist. How do I know I’ll services and whether these are covered
be covered? as outpatient care, please contact your
You should check with your insurance insurance company.
company. Most managed care plans, If you are a Medicare subscriber,
health maintenance organizations (HMOs) observation status is not considered a
and point of service (POS) plans require hospitalization and does not affect your
a referral from a primary care physician Medicare Part A benefits. No hospital
before they will cover a visit to a specialist. days are used, and the Part A deductible
Please discuss this with your primary is not required. This also means that
care physician before scheduling an observation status does not count toward
appointment with a Cleveland Clinic the three day qualifying stay requirement
specialist – and if a referral is required, for admission to a skilled nursing facility.
make sure you get one. If a referral is Observation status is covered by Medicare
necessary and you do not get one, your Part B. There is an annual deductible and
appointment with the specialist may co-pay for these services. In addition,
have to be rescheduled, or you may be you should know that while you are
responsible for paying for the visit. in the hospital during an outpatient
observation period, Medicare does not
pay for “self administered drugs” such as Billing
oral medications, eye drops, creams, ear
drops, ointments, inhalers, suppositories, 1. Will I receive one bill – or separate bills –
and insulin – even if a nurse administers for the care I receive at Cleveland Clinic?
them to you. If you have questions about When you receive care at any of our
observations status services covered by Cleveland Clinic inpatient or outpatient
Medicare, please call 1.800.MEDICARE facilities, you will receive one billing
(1.800.633.4227). statement for all Cleveland Clinic physician
and hospital services. This same bill will
5. I don’t have health insurance. include charges for medical or technical
What are my options? services, supplies and equipment as well
Please call PFS at 216.445.6249 or as physician and clinical professionals,
toll-free at 866.621.6385 and we will be treatment and procedures. The statement
glad to tell you about financial assistance will show any co-payments or deductible
programs available through the government payments you made.
and Cleveland Clinic and how to apply One exception: If you receive care from
for them. an independent physician who is affiliated
Financial assistance applications can be with Cleveland Clinic but not part of our
downloaded from http://my.clevelandclinic. group practice, you will receive a separate
org/patients-visitors/billing-insurance/ bill for these services.
2. How do I make a payment?
6. Do I have any options if I recently You have several options:
lost my job? • Cash, check or money order
If you are unemployed and no longer • All major credit cards
covered by insurance, you may be • Electronic checks
eligible for COBRA, an insurance program
established by the federal government
• 3-month payment plan
to provide out of work individuals with
temporary healthcare benefits. If you • USBank loan
cannot make the monthly payments,
you may be eligible for a program where 3. Can I pay my bill online?
Cleveland Clinic pays COBRA on your Yes. You can sign up for MyAccount to
behalf for a specific course of treatment receive your billing statement electronically
and period of time. If you do not qualify, and pay online. Here’s how to enroll:
you will be evaluated for other assistance Log in to: myaccount.clevelandclinic.org
Choose: Sign Up Online
Complete: Demographic screens
4. What can I do to ensure a smooth classified as “Physician and Clinical
billing process? Professionals”.
We encourage you to take these steps:
• Bring your most recent insurance cards 6. What does “provider based” mean?
and picture ID to your health visit. Provider based is a Medicare classification.
• When making an appointment and It means that hospitals have met specific
arriving for your health visit, make sure Medicare regulations to have their
we have your correct address. outpatient doctors’ offices and clinics
• Check your insurance plan to find classified as provider based. Most large
out what is and isn’t covered. If you hospital systems are classified as provider
have questions, please contact your based by Medicare, which results in
insurance company before your uniform billing.
• Confirm with your insurance company 7. Does provider based billing apply to me if
that Cleveland Clinic health system is I am not covered by Medicare?
a contracted provider of services for Yes. Provider-based billing applies to all
your plan. patients, not just to those covered by
• If your insurance company requires Medicare.
a co-pay or deductible payment for
your health visit, be prepared to pay. 8. How does provider-based billing affect me
Services may be postponed if a payment if I have Medicare?
isn’t made. The charges listed under Hospital Services
will be billed to Medicare Part A. The
5. On my bill, why did I get charged a physician and clinical professionals charge
facility charge when I was seen in a will be billed to Medicare Part B. You will
doctor’s office? receive two Medicare Summary Notices
Cleveland Clinic’s physician offices and (MSNs), one for Part A and one for Part B.
outpatient clinics are considered hospital
If you have secondary or supplemental
outpatient departments (also called
insurance, we will submit any balance
provider based) by Medicare. This means
to that insurance plan. If your secondary
you will see a facility and/or treatment room
insurance does not cover the balance,
charge under the Hospital Services section
or if you do not have secondary or
of your billing statement.
supplemental insurance, the balance
Facility charge covers the use of the room will be billed to you.
and any medical or technical supplies or
equipment. Your billing statement will
also include charges for doctor’s services,
treatment or procedures, which will be
9. I am covered by Medicare but don’t have from Medicare. Some insurance companies
supplemental insurance. How can I find may apply these charges to your annual
out what my Part A and Part B charges deductible. To find out what will be
will be? covered, contact your insurance company.
Medicare requires that we give you an
estimate of your Part A and Part B charges 11. If I am unable to make full payment
if you do not have secondary insurance. immediately, can I set up a payment plan?
These amounts may be different, depending Yes, please contact our Credit and
on the services you receive. Listed below Collections Department at 216.738.5300
is an example of what a Medicare patient or 1.866.737.4358 to establish a payment
may be responsible to pay in 2012 if there plan or to learn about our loan program.
is no secondary insurance.
Please be aware that patients are responsi-
Part A (Hospital Services) ble for account balances, and payment
Office visit level 1 $11 is due upon receipt of the bill. Cleveland
Office visit level 5 $35 Clinic employs third-party collection
Emerg Dept visit level 1 $10 agencies to help us resolve unpaid
Emerg Dept visit level 5 $65 balances. If you are unable to pay your bill,
Joint injection $36 you may be eligible for financial assistance.
Chest x-ray $9
12. I was given an estimated cost of services
Skin biopsy $21
and I made the required deposit for half
Part B (Physician/Professional) that amount. How will that be handled
Office visit level 1 $5 once the actual bill is determined?
Office visit level 5 $32 You will receive a statement for the
Emerg Dept visit level 1 $4 remaining balance. Payment is due upon
Emerg Dept visit level 5 $35 receipt. If the deposit turns out to be more
Joint injection $10 than your final bill, you will be refunded
Chest x-ray $2 once the insurance balance has been
Cystosocopy $26 settled. If there was no insurance involved,
Skin biopsy $10 we will refund your money once all charges
You can get additional estimates by have been totaled.
calling PFS Customer Services toll free at
1.866.621.6385 or by seeing one of our 13. Whom should I contact with questions
financial counselors. about my billing statement?
If you have questions, need to update
10. How does provider-based billing affect me your insurance information, or would like
if I am not covered by Medicare? an itemized statement, please call PFS at
The way your insurance company handles 216.445.6249 or 1.866.621.6385.
provider-based charges may be different
Financial Assistance for Cleveland Clinic financial assistance.
In Florida, we do not contract with a
1. Is financial assistance available? Medicaid vendor company, but we do have
Yes. The Cleveland Clinic Health System a representative on site to assist you.
has a generous financial assistance
Patients who do not qualify for HCAP or
program. Please see the eligibility
Medicaid will next be considered under the
Cleveland Clinic financial assistance policy.
• At Ohio facilities, must be a resident
of Ohio. Important point: Until patients are
• At Florida facilities, must be a resident approved for Medicaid, they will continue
of Broward or Palm Beach counties; to receive billing statements from
distance to other providers will be Cleveland Clinic.
considered for eligibility. Please be aware that Cleveland Clinic
• At Nevada facilities, must be a resident does not contract with most out-of-state
of Nevada and reside within a 150-mile Medicaid plans. Patients covered by
radius of Cleveland Clinic facilities. Medicaid in other states will need to seek
• Must follow the Medicaid eligibility medical services within their home states.
process with a Cleveland Clinic
representative or one of our vendor 3. How do I apply for financial assistance?
companies. To get a financial assistance application,
Cleveland and Nevada patients can call
2. How does financial assistance work? 216.738.5300 or 1.866.737.4358
Cleveland Clinic participates in the Ohio or visit http://my.clevelandclinic.org/
Hospital Care Assurance Program (HCAP). patients-visitors/billing-insurance/financial-
Ohio residents who apply for financial assistance.aspx.
assistance are considered for HCAP Florida patients can call 954.689.5166.
coverage. Applicants are screened If you apply, you will receive a letter within
for Medicaid assistance in Ohio, Florida 14 business days explaining if you qualify
or Nevada, depending on where they for financial assistance and the level of
receive care. coverage that will be provided.
A financial counselor will ask you a few
questions to see if you meet the initial 4. If I qualify for financial assistance,
requirements. If you do, you will be will I need to re-apply at some point?
referred to one of our Medicaid vendors, Yes. You will be asked to reapply for
Human Arc of Ohio or Firstsource every inpatient service and every 90 days
Solutions. They will work with you and the for outpatient services. You will also be
state to secure Medicaid coverage. required to reapply if your family income
Please comply with our vendor company changes. If you qualify for less than
and the process so you can remain eligible 100% financial assistance coverage,
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you will be asked to pay 50% of the with their ODJFS caseworker proof of
estimated balance for either elective out-of-pocket medical expenses that are
inpatient or outpatient services prior to his or her responsibility to pay. These
scheduling and to make arrangements expenses are totaled and compared against
for payment of remaining balances after a monthly Spenddown dollar amount set
services are provided. by ODJFS. (Expenses covered by other
insurance plans are not eligible toward this
5. Can I receive financial assistance if my amount.) Once the monthly Spenddown
income is too high? amount has been reached, the individual
A patient may qualify for financial is eligible for Medicaid – and the use of a
assistance in exceptional situations, even Medicaid card issued by the county where
if their annual family income is greater they live – to cover medical expenses for
than 400% of the federal poverty the rest of the month.
guidelines. The patient must provide Here are a few important points to
information to support the exceptional remember about the Spenddown program:
medical circumstances and will be
considered for assistance if your total • Your date of Medicaid coverage begins
annual medical expenses are greater on the date the total amount of your
than 25% of their annual family income. out-of-pocket medical or pharmacy
All requests for exceptional circumstances bills equals your monthly Spenddown
will be reviewed by the Financial amount.
Assistance team. • Once your Medicaid card has
been issued by the county, you are
6. Could I qualify for Ohio Medicaid’s responsible for paying the expenses
Spenddown program? used to satisfy the monthly Spenddown
If your income is too high for Medicaid but amount.
you are elderly, blind or have a disability, • Cleveland Clinic patients who have
you may still qualify for Medicaid through been approved for the Ohio Medicaid
the Spenddown program, which allows Spenddown program may use their
certain individuals to deduct medical current or past unpaid medical or
expenses from their income so that it falls pharmacy expenses to satisfy their
within Medicaid guidelines. monthly Spenddown amount.
• You can use past unpaid medical bills
7. How does the Spenddown program work? to satisfy your monthly Spenddown
amount for more than one month.
Eligibility for the Spenddown program is a
Example: Your monthly Spenddown
monthly process determined by the Ohio
limit is $100. You already have $800
Department of Jobs and Family Services
in past qualifying medical expenses,
(ODJFS). The Medicaid Spenddown
which is the equivalent of eight months
Program requires an individual to share
of Spenddown expenses.
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• In some Ohio counties, you can “pay in” program offered by the Ohio Department
your monthly Spenddown amount – just of Health (ODH). BCMH links families of
like an insurance premium – to have children with special healthcare needs
your Medicaid card issued. You simply to a network of quality providers and
go to the county office and pay your helps families obtain payment for the
monthly Spenddown amount. services their children need. These needs
can include care for medical conditions
8. How can Cleveland Clinic assist me that require ongoing treatments, such
with the Spenddown process – and what as diabetes, heart defects, chronic lung
can I do? disease, cancer and hearing loss. BCMH
All Cleveland Clinic hospitals have an on may pay for some services that are not
site financial counselor who can guide you covered by insurance and/or Medicaid.
through the process by: If your child needs special support and
• Printing itemized statements outlining services through BCMH, our financial
your charges. counselors and social workers will refer you
• Faxing information to your caseworker to our vendor, Firstsource Solutions, who
so your Medicaid card can be issued. will work with you to establish eligibility for
BCMH coverage. If your child is not eligible
• Providing you with other information to
for BCMH, your family may be eligible for
assist you in resolving balances on your
other financial assistance.
Here’s how you can help: Special Topics
• Provide the financial counselor with
1. I am an international visitor to the United
your caseworker’s name, telephone
States. Are there special services for
and fax numbers and your monthly
patients like me?
Yes. Global Patient Services (GPS) offers
• Follow up with your caseworker to be
a wide range of support services for
sure charges have been received and
international patients and their families.
the Medicaid card has been issued.
GPS has a full-time, multi-lingual staff who
• Once the Medicaid card has been can help facilitate all financial aspects of
issued, provide billing information to an international patient’s visit, including
PFS Customer Services toll free at insurance verification and pre-payment
1.866.621.6385. arrangements for patients who will be
paying their charges themselves.
9. I have a child with special healthcare
GPS can also help with scheduling
needs. Are there financial assistance
medical appointments, airline and hotel
programs that can help?
arrangements and ground transportation,
The Bureau for Children with Medical as well as activities for family members
Handicaps (BCMH) is a healthcare
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assisting the patient. For more information, Learn the difference between Medicare
please contact Global Patient Services in and a Medicare HMO, find out if you
Cleveland at 216.444.6404 or send an need a supplemental plan, discover
email to email@example.com. In Florida, call what is not covered by Medicare, and
954.659.5080. have your questions answered by
2. I don’t speak English. Can I get an • Need help understanding your
interpreter? hospital bill?
Yes. Our Global Patient Services (GPS) Hospital bills are sometimes confusing.
area provides interpreters to assist with You are invited to attend our Patient
communication in many languages. To Education seminars where our customer
arrange for these services, please contact service and billing experts can help
GPS in Cleveland at 216.444.6404 you understand your Cleveland Clinic
or send an email to firstname.lastname@example.org. billing statements. They also will explain
In Florida, call 954.659.5080. The co-insurance and deductibles and how
registration staff also can assist in those items are displayed on your bill.
obtaining interpreter support.
Reservations are suggested. Please
call 216.636.1121 to reserve
3. Does Cleveland Clinic offer any your place. For a full calendar of
educational courses to help patients or upcoming sessions, please go to http://
family members understand insurance my.clevelandclinic.org/Documents/
and billing? Patients/patient-education-sessions.pdf
Yes – we offer several free educational
forums, and they are open to everyone.
Here are some of the topics:
• Puzzled by health insurance and
Learn how to read your evidence of
coverage, explanation of benefits, and
Cleveland Clinic billing statement; find
out what specific insurance terms mean
and have your questions answered by
• About to retire?
If you are 63 or older and are still
employed or do not have Medicare,
prepare for the transition from
commercial insurance to Medicare.
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If you have questions about any of the
information in this brochure, your bill or
financial assistance, please contact Customer
Service. We will be happy to assist you.
216.445.6249 | 866.621.6385
Patient Financial Services
Patients First Support Services
6801 Brecksville Road / RK10
Independence, OH 44131