Medical Billing Frequently Asked Questions
General Billing Overview
I’m interested in learning more about my Insurance Plan. How do I Verify My Own Health Benefits and Coverage?*
Due to growing variability in Insurance Plans and Payors; the fact that many Integrative Health Services are not clearly detailed on Insurance companies’ websites; and massive nationwide staffing changes brought on by the Pandemic: It has become impossible to verify every single plan for the many thousands of patients who choose our Clinics each year for healthcare.
We want to be completely transparent and provide you every opportunity to inform yourself of your insurance coverage and benefits before receiving treatment at Mountain Spirit. In order to reduce confusion, we advise all of our Patients to call the Customer Service number on their Insurance Card, and ask about the specific benefits and coverages on their Insurance Plan. Since health insurance is a contract between Members (Patients) and Payors (Health Plans), your health insurance company is responsible for reporting these details, when asked directly by you.
* It is highly recommended to get the name of the Customer Service Representative that you speak with at your Insurance Company as well as a Call Reference Number. This is the best way to document the information you receive.
We advise that you verify the following benefits with your insurance plan: If you are asked, all services will be provided in an “Office” setting.
Some of our healthcare is Primary Care, typically when you see one of our Primary Care Providers. The remainder is generally regarded as Specialist Care, for example when you come in for Acupuncture, Occupational Therapy, MyoFascial Release aka Medical Massage Therapy, Naprapathy / Chiropractic, etc.
Inquire regarding your General Benefits and Coverage for services you may choose here, including:
Primary Care Medicine aka Family Practice
Acupuncture
Chiropractic / Naprapathy
Manual Therapy / Occupational Therapy aka “Physical Therapy” and/or “Rehabilitative Therapy” - MyoFascial Release (aka ‘Medical Massage’) are generally found under ‘Physical Therapy’ benefits
*If any of the above services are NOT covered, inform our Staff immediately. We’ll share options with you, and as always you will select how you choose to Schedule.
It is also very important to Verify if Prior Authorization* is required for the specific CPT code:
97140 - Myofascial Release (MFR) / Manual Therapy
*If Prior Authorization is REQUIRED, please inform our staff so that we may begin that process BEFORE you receive those services in order for them to be covered by your insurance plan.
When checking-in for your first appointment at our clinic or your first appointment of each Calendar and/or Plan Year: Be sure to advise to our Staff how you would like to handle paying for your services at our clinics - Self Pay, Insurance-Based, or a mixture of both based on your specific Health Plan.
Our current Self Pay rates listed on our website’s Prices & Policies Page HERE. These Self Pay rates will be collected at the Time of Service, for any healthcare services which at the time of visit(s):
a) Are not covered by your Health Plan; or
b) When you have not yet provided your then currently active, valid Insurance Card; or
c) For Health Insurance Companies or Plans for which Mountain Spirit is not in Network; or
d) You have signed an Opt-Out Form requesting Self Pay for service(s) at Mountain Spirit.
I was just seen at Mountain Spirit for an appointment. What happens now?
The Medical Billing process can take up to three to six months for a claim to be completed. This is a general timeframe and can take more or less time, dependent upon a number of factors.
· It can take up to thirty days for: a provider to complete the Medical note, the Certified Professional Coder to code the claim created from your Provider’s Medical notes, and the claim to be sent to your insurance via our electronic clearinghouse.
· The claim can then be processed by your insurance, which may take up to an additional forty-five days. Once your insurance has processed your claim, they will send you an Explanation of Benefits and send us a payment with multiple patients’ benefit details to be posted to each account.
· It can then take up to another thirty days for us to receive your payment details from your insurance and to post your insurance’s payment. At this time, we will post the payment you made at the time of service and send you an invoice for any amount your insurance deems as your responsibility.
· An additional thirty to sixty days may be generated if the claim was missing any information or if coding for that specified insurance was changed or altered by the insurance company, or erroneously denied. Mountain Spirit does all we can to submit clean claims in a timely fashion as a courtesy to our patients.
Mountain Spirit does not make any benefit determinations. We send your claim and post your insurance’s benefit determination, but we are not responsible for applying or determining what your cost is for your claims (patient responsibility). Only your insurance carrier can determine your benefit applications.
We will attach a statement to your invoice. This will advise you of the balance and any payments you may have made on the date of service. If your insurance is determining more patient responsibility than what was originally quoted you should call them to inquire or rectify as Mountain Spirit does not make any benefit determinations.
Who and what is Grasshopper Natural Medicine?
Grasshopper Natural Medicine (GNM LLC) and Mountain Spirit Integrative Medicine (MSIM LLC) are the same Company. GNM LLC is our corporate entity, and we are doing business as Mountain Spirit. Typically our health insurance contracts are written under GNM LLC, however some also list our dba MSIM LLC. If you have received an explanation of benefits or bank receipt with the name Grasshopper Natural Medicine, it is for service or product at Mountain Spirit.
If I request a back-to-back appointment, what does that mean and how is that billed?
Back-to-back appointments are Acupuncture and Medical Massage (or Physical Therapy) appointments booked for one service day. This does not mean they are one appointment. They are two separate appointments and in most cases they are performed by two separate providers of service and are booked as a “back-to-back” for the patient’s convenience.
Because these are two appointments that can be structured to accommodate the patient for the services to be provided in one service day, they are billed with two separate CPT (Current Procedural Terminology) codes identifying the separate services to your insurance. A medical visit may also be billed if the service criteria is present when our Billing Department reviews your medical note for insurance submission. If your insurance applies more than one copay to these separate services, that is a determination they will make according to your insurance contract and Mountain Spirit is not responsible for insurance application of patient responsibility.
Why could I have a Patient Share payment due for a Physical or ‘Annual Exam’?
Why might I have a CoPay / Deductible / Patient Share due, for what I thought was my annual Physical or ‘Annual’ examination?
An Annual Exam or ‘Physical’ is a type of preventive care visit with your Provider that focuses solely on your overall health and how to stay healthy. Typically ACA compliant health insurance plans allow an Annual or preventive care visit only once per year, and further only one within any consecutive period of 366 days. However, such a preventive visit may turn into an ‘office visit‘ that costs you money, if you focus on or request anything related to active medical condition(s) — this includes asking for specific procedure(s), lab work, medication(s), refill(s), referral to specialist(s) or imaging, for any symptom / condition.
A physical examination preventive care visit is different from an office visit:
The purpose of a preventive Physical / Annual Exam visit is to review your overall health, identify risks and find out how to stay healthy. Affordable Care Act benchmark-based plans typically cover 100% of a preventive visit when you receive only a Physical, and see a Provider clearly listed in your plan’s directory.
The purpose of an Office Visit is to discuss or get treated for a specific health concern or condition. You will have a Patient Share for the visit reflected on your EOB in the form of a copay, deductible, and/or coinsurance.
If you schedule a preventive care visit and then ask your Provider about a specific health concern or condition, the Clinic codes and bills the appointment (also) as an Office Visit. In such cases, your choice in doing so will almost certainly trigger your Insurance Plan to apply a Patient Share due for such a visit. Insurance companies who contract with Providers, such as our Clinics, require us to collect the Patient Share(s) listed on their Explanation of Benefits aka “EOB” which they alone determine based on a Patient’s own chosen health plan.
Our Provider has no possible way of knowing all that you may request or discuss during any visit, prior to the visit’s completion. Therefore, our Clinic requires payment of your Copay at all Primary Care visits at Mountain Spirit, even for those scheduled as Annuals and Physicals. Once the visit is complete, our Clinics bill our contracted third party payor in a timely manner, and only once an Explanation of Benefits is completed by the relevant health plan, will we know whether a Patient Share is due. If it is, we bill any remaining balance due to the Patient based on our Billing Policies described herein. If one is not, the Patient will advise our Clinic whether they would like a refund or credit to their account here.
What can I discuss at a preventive visit without getting charged?
During your preventive care visit, your Provider will look at your health risks and talk with you about:
Your current health
Your family health history
Past illnesses and surgeries
Risks you may have for specific conditions
How to maintain a healthy lifestyle
A preventive care visit that includes only the above - Plans often though not always cover such services 1 time per year. However it’s up to you to know how your plan works. If it has been less than 1 year since your last Preventive Visit, or your Plan is not conforming with the Affordable Care Act, then you will likely have a Patient Share due.
An office visit -
Your plan typically will require you to pay Patient Share(s) for these services:
Certain blood tests to check such things as anything related to a symptom
Discussing or getting treatment for a specific health concern, condition or injury
Lab work, X-rays or additional tests related to a specific health concern, condition or injury
Various immunizations
Various specialized screenings not currently recommended by a Patient’s demographics; especially advanced screenings such as genetic testing, etc
Proper preventive care is important to help you live a longer, healthier life. A preventive checkup can help prevent disease before it starts and detect problems early, before they cause serious illness.
How often and what kind of preventive care you need depends on your age, gender, health and family health history. Look over the guidelines for men, women and children in our preventive care recommendations (PDF).
Call the number on the back of your member ID card to find out what your plan covers.
What if I am confused or dissatisfied with the Patient Share as determined by my Health Insurance Plan?
It is your responsibility alone to understand how your health plan works. What it does and doesn’t cover. What your total Patient Share is due as defined by your Health Plan’s Explanation of Benefit for each Visit (this is the total sum of CoPays, CoInsurances, Deductibles, and Out of Pocket Maximums for each Visit and Plan Year). The Member alone is responsible to promptly pay the Patient Share determined by your Insurance Plan for each Visit’s Explanation of Benefits that you receive. Mountain Spirit cannot guarantee how your insurance will process your claim once they receive it. Because insurances change their rules and processes for claims for each benefit year, Mountain Spirit staff cannot know how each insurance will process claims for each patient, individually. Therefore if you believe your Insurance Plan processed your claim incorrectly, or you do not understand how they arrived at your Patient Share for any healthcare visit(s): You may contact your insurance to advocate for yourself and make a formal Appeal. Mountain Spirit simply cannot get involved in an Appeal to your Insurance Company, as this is the Member’s sole responsibility.
Glossary of Terms
What is a Copay?
Copays are the amounts your insurance applies to at a flat rate per particular types of visits or treatments. Copays are applied at the discretion of your insurance, and can be applied to one or more services per day, dependent on your insurance’s contract with your plan holder, which in most cases is your employer group.
Your copay is due and will be collected at the time of service for treatment in our office.
Primary Care CoPays
We are proud to be an independent Multi-Specialty group practice, allowing us to operate with greater transparency and a strong focus on the Patient-Provider relationship. With this in mind, we want to clarify certain insurance and billing matters related to your care. Annual wellness visits include a check of your height, weight, bloodwork and vital signs. You and your Practitioner will discuss any changes to your health, and will work together to create a personal health plan for the year ahead. Please note, Insurance Companies determine when and whether CoPays are due for Primary Care visits. Because of this fact, we collect a CoPay at the time of each Primary Care Visit, and submit all of the facts regarding each Visit to your Health Plan via Medical Claims. If your Plan determines that no CoPay was due for the visit, we’re happy to refund such amounts as soon as the relevant Explanation of Benefits is received showing zero Patient Share for a Primary Care visit. Otherwise, when the EOB shows a CoPay is due as part of the Patient Share, the CoPay is retained for such Dates of Service.
CoPays for Visits with our Women’s Health Specialist
Because of Lori Pearson Kramer’s experience and background as a Women’s Health Specialist, the insurance companies with which we are contracted require that a specialist copay is due for each visit with her.
Be prepared to pay the Specialist CoPay for each and every visit whenever you see Lori for any reason!
CoPays for Multi-Provider Visits
Our Patients sometimes choose Back to Back visits in which they see more than one Provider on a given Date of Service. We have no guarantee whether your Plan will require one or more CoPays for such Multi-Provider Visits. Because most plans require two copays to be collected on such days, we collected two copays at the time of such visits. If you have questions on how your plan will apply multiple copays for services billed under the same provider, you should call your insurance directly.
Mountain Spirit cannot guarantee the way your insurance will process your claim. If more than one copay is generated by your insurance, per date of service, and the policy holder (patient) disagrees with their insurance’s determination, the policy holder (patient) will have to appeal their insurance directly as benefits change subject to your Health Insurance’s contract with your employer group/health insurance exchange guidelines. There is no guarantee they will edit the amount due, as most plans now require 2 copays for such visits. In the very rare circumstance that a leaser amount is defined by your insurance as the Patient Share on the EOB for such a day, please contact Mountain Spirit to request a review of your account; if our Billing Team finds any overpayment, we’re happy to either make a refund, or apply a Credit to your account here.
What is a Co-insurance?
Co-insurance is a percentage amount your insurance applies to particular types of visits or treatments. Co-insurances are the plan’s apportionment of your patient responsibility based on the overall total of the allowed, not billed, amount.
Your co-insurances will be billed by invoice after the claim is processed and posted to your claim.
What is a Deductible?
Deductibles are a total amount your insurance applies to particular types of visits or treatments that must be paid by you, the patient, prior to insurance process and payment on your claims. Deductibles are outlined in the contract between the patient and the insurance and must be satisfied by the patient making payment to the provider of service for the total amount on each explanation of benefits to complete your deductible.
Your deductibles will be billed by invoice after the claim is processed and posted to your claim.
What is a Claim?
A claim is request for payment for a service covered and eligible for payment by an insurance company. It can be submitted on a form Physicians use for Billing called a HCFA-1500. It includes all Diagnosis and CPT (Current Procedural Terminology) codes regulated by the Federal Government to process your eligible expenses through your health insurance, along with the necessary information for the patient to be recognized as the insured and payment information for the provider.
The claim is submitted by Mountain Spirit, however, the claim for service is from the insured and to the insurance. The contract for payment is between the two parties and Mountain Spirit is the provider of service. Mountain Spirit bills for the services rendered to the patient. If the services are unpaid by the insurance, the patient, and receiver of care, is ultimately responsible for payment.
What is a Benefit Limitation?
A benefit limitation is the limit set by the insurance to advise the patient of the maximum service the insurance contracted to pay for the patient. It may be a visit number limit or a monetary total maximum. Benefit maximums are not tracked by Mountain Spirit for each individual patient as it is the receiver of care’s responsibility to be aware of the benefit limitations within their plan. We will verify your benefit limitations and advise you of the limit, however we cannot alert you if you are close to hitting limitations. You must track these for your personal use.
Invoice and Payment Questions
How and when can I expect to receive my invoice?
Your invoice will be sent once payment and benefit determination is made by your insurance, the explanation of benefits is received in our office, and payments and adjustments are posted to your claim. Invoices are sent via email, so please check your spam filters to ensure your invoices are not being incorrectly directed. This can take up to ninety days from the date of your service, and may take more if there are any incorrectly processed amounts on your claim that need to be appealed, corrected, or changed.
Why am I getting this bill and what is it for?
If you are receiving an invoice from Mountain Spirit, your insurance has applied this amount toward your responsibility or you have had a late cancellation or no show in our office.
Patient Responsibilities can be copays, deductibles, coinsurances, or other amounts which your insurance has deemed your responsibility. If you have questions about these amounts, please locate your Explanation of Benefits from your insurance from the date in question and call your insurance to inquire.
How can I pay my invoice?
To pay your invoice with a credit card or direct bank transfer, please click the "Pay now" button on the emailed invoice. If you do not want to re-enter your credit card information, you can call our office and we can charge the card on file for you. You can also pay your invoice in person at either of our two offices with cash, check, or credit/debit card. If you would like to mail a check, please be sure to call and let us know before you put the check in the mail, so we can expect your payment and do not charge your card on file.
Why have I received two invoices for the same date of service?
Please carefully look at each invoice and its attached statement. Depending on your insurance coverage, if you had two services in one day, they may have been billed on separate claims because the providers have different specialties. This will generate a separated patient responsibility from your other visit on the same day.
You may also receive an additional invoice if your insurance company has reprocessed a claim and your patient responsibility amount has changed.
How long do you wait to charge my card?
For appointment balances, we send your invoice and give you seven days to pay the invoice, or call us to change or the correct card on file. After the seventh day, your card will be charged.
For no-show or late cancellations, 48 hours are given to charge your card. If you have had an emergency, please forward proof of emergency in the response to the emailed invoice. Our Management Team will review your proof to verify if the emergency was a valid excuse for your late cancellation or no-show fee.
What do I do if my card on file declines?
We will send you an email advising that your card has declined. Contact our office within 48 hours to correct the card on file. If the card is not corrected or replaced, any appointments scheduled for you will be removed and no other appointments can be scheduled until you have updated your information. Furthermore, you are still responsible for paying any and all balance(s) then currently due, immediately. We have the right to require certified funds for such payments, including but not limited to via a certified Cashier’s Check. If you misunderstood a balance due that was charged to the Card(s) you placed on file, and chose to ‘dispute’ such charge(s), you are responsible for all fee(s) charged by your credit card company and/or our credit card processor.
Insurance and HSA/Flex Processing Questions
What should I do if my insurance makes a mistake in processing my claims?
If you believe your insurance company has made an error in processing your claim, please contact them to request they correct it. Then please contact our office to advise they will be correcting it. Dependent upon the issue, we may ask that you pay the balance until your insurance is able to correctly process your claim or give you an extension for your insurance to properly adjudicate your claim.
Why are the amounts billed to my insurance so high?
The billed amounts that are sent to insurances are set by the State of New Mexico. Mountain Spirit uses the New Mexico Worker’s Compensation Fee Schedule, as set by our State government, for billing purposes. This is the standard when billing medical services, and updates at the beginning of each calendar year. Mountain Spirit does not set our rates nor are we compensated those amounts directly when billing contracted health insurances.
Each insurance we have a contract with pays according to their contracted amounts. Patients are only billed for the patient portions on each Explanation of Benefits and if any services are denied, in accordance with our contract with your insurance.
Why is my patient responsibility amount different than what was quoted?
Mountain Spirit quotes the benefit to you that we receive from your insurance. We cannot guarantee how your insurance will process your claim once they receive it. Because insurances change their rules and processes for claims for each benefit year, Mountain Spirit staff cannot know how each insurance will process claims for each patient, individually. Therefore you must contact your insurance if you believe they have processed your claim incorrectly.
Do I have to pay my deductible every time?
We have no way of knowing or keeping track of each patient’s deductible and how they are meeting that elsewhere, therefore Mountain Spirit cannot advise you if your deductible has been met until we receive your EOB from your insurance showing that your deductible is no longer applying to services here. If you have questions about where you are in meeting your deductible you should call your insurance prior to your appointment so that you can make informed decisions about meeting your deductible.
My EOB shows I met my out-of-pocket/deductible, why am I still getting invoices that show I owe an out-of-pocket/deductible amount?
Insurance providers calculate your out-out-pocket maximum as they process your claims. Because patients receive EOBs for completed claims before we have had a chance to post patient responsibility on older claims, you may have received the explanation of benefits for a more current date of service prior to us applying your patient responsibility for an older date of service. Please double check your date of service on your invoice against the EOB that shows you met your out-of-pocket/deductible. If you find any discrepancies, please call our office.
I have received multiple invoices and am confused by the amounts and dates. How do I figure out my billing?
Each time we send an invoice we will attach the statement to the invoice. You can locate the date of service in this document. You can then match the date of service to your explanation of benefits from your insurance to verify the amount we bill is the amount you owed for that date of service minus any copayment amounts taken at the time of service. The paid amounts will be notated in the statement, attached to your invoice.
Please keep track of your visits against your explanation of benefits. We have a small billing staff and will not be able to match these dates or pull EOBs for each individual patient. We changed our billing processes in 2019 to ensure all invoices were simple and trackable if you are reviewing your EOBs along with your invoices.
Please note: we do not include gratuity or herbal purchases on invoices as these are not billable items to insurances. Please track these items for your personal use.
I received an invoice for an unexpected large amount, and I cannot pay it all at once. Am I able to schedule a payment plan, or have an extended due date?
We do our very best to advise you of deductibles, copays and coinsurances prior to your visits at Mountain Spirit so that you may properly plan for your health expenditures, but we understand sometimes insurance plans make errors that we cannot be prepared for. If this is your situation please email billing@mountainspiritnm.net, explaining your hardship and our management team will contact you with options for your unique situation.
My Health Savings Account (Flex) card requires a detailed receipt for my card usage, how do I obtain this?
You can inquire with either the Front Desk or the Billing Department if you require detailed receipts. We will send you a statement by email showing the necessary information your HSA card company will accept and process. This can take up to thirty days, but we will send the information as soon as we can to your email on file.
What is in the receipt for my HSA/Flex?
Your HSA will require Diagnosis and CPT (Current Procedural Terminology) codes regulated by the Federal Government to process your eligible expenses. We will supply this information for contracted insurances we bill and Self Paying patients who choose Medical Documentation options.
Billing Questions regarding Self Pay Visits
I am a self-paying patient and I need notes from my treatment for personal reasons. Can I get this?
If you would like Medical Documentation on a self-paying service, there are options available to you for an added administrative cost amount. Please see our PRICES page that will outline the cost to you. If this is the option you require, please alert the front desk at your next appointment to add the correct fee for a copy of Medical documents sent to you either via email or USPS. Medical documents are legal documents and our providers document these visits just as an insurance related visit would be documented. This service is available for Acupuncture, Chiropractic, Naprapathy, Occupational Therapy, and MyoFascial Release (commonly referred to as ‘Manual Therapy’ or ‘Medical Massage’).
If the added administration fee is not paid at the time of service, your provider may be unable to document the needed information at the time of service. Please be sure to alert the front desk prior to your appointment to ensure you will be delivered the appropriate information.
If I paid for a service myself and I have Health Insurance that covers the service can you submit my claim?
Self Pay services are not required to include complete insurance-reimbursable Medical Documentation. If you have had a treatment in the past and paid Self Pay rates, without clearly requesting and paying the additional charge for Medical Documentation, then no medical documentation can be provided to your insurance once the treatment has completed. Please request we verify your health insurance coverage prior to any appointments so that we have our Providers complete Medical Documentation necessary to qualify for potential Insurance reimbursement.
Thank you,
Mountain Spirit Billing Department
Billing Team: (505) 988-2449 Extension 4