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					Understanding
Insurance and
Our Billing Process
                                                Understanding
                                                Insurance and
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
                                                my.clevelandclinic.org/patients-visitors/
have about insurance, billing and financial
                                                billing-insurance/default.aspx
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.
                                                     deductible payment?
                                                     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-
           clevelandclinic.org

                                                                      |1|
     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




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     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.
     financial-assistance.aspx
                                                   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
                                                        • myaccount.clevelandclinic.org
     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
     programs.
                                                        Choose: Sign Up Online
                                                        Complete: Demographic screens




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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.
         health visit.
     • 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




                      |6|                                                  |7|
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
     Cystosocopy                            $95
                                                  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



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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
     requirements below:
                                                        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,



                     | 10 |                                              | 11 |
     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.




                     | 14 |                                         | 15 |
     • 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.
       account.
     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?
       Spenddown amount.
                                                       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



                     | 16 |                                             | 17 |
     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 interna@ccf.org. In Florida, call       what is not covered by Medicare, and
     954.659.5080.                                    have your questions answered by
                                                      Medicare experts.
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 interna@ccf.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
       billing?
       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
       insurance experts.
     • 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.




                     | 18 |                                         | 19 |
Additional Questions
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.



Customer Service
216.445.6249 | 866.621.6385




Prepared by
Patient Financial Services
Patients First Support Services
6801 Brecksville Road / RK10
Independence, OH 44131




      clevelandclinic.org

				
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