Medical Billing Frequently Asked Questions

 

General Billing Overview

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 is Grasshopper Natural Medicine?

Grasshopper Natural Medicine and Mountain Spirit Integrative Medicine are the same business. It is the name we first used, and have our health insurance contracts under. If you have received an explanation of benefits or bank receipt with this name, it is for service or product at Mountain Spirit.

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 will be taken at the time of service for treatment in our office.

  • Traditionally, only one copay is required per date of service per provider specialty, however we have no guarantee your plan will follow traditional guidelines. 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.

  • If your insurance is applying more than one copay per date of service erroneously you will have to appeal your insurance to ask them to correct the issue. If they are applying more than one copay per date of service intentionally you can contact your employer group to request the issue be investigated as we can only quote the benefit information given to us at the time your insurance verifies your benefits via the web or phone. Mountain Spirit cannot guarantee the way your insurance will process your claim and 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.

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 reimbursement. Deductibles are a contract between the policy holder and the insurance and must be satisfied 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. 

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.

Self Paying Questions

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 or SPA 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 Myofascial Release and Acupuncture visits.

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 or SPA services do not include Medical Documentation. If you have had a treatment in the past and paid SPA rates, 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 bill your health insurance.

Thank you,

Mountain Spirit Billing Department

Clinic Phone (505) 988-2449 X 4

Fax (505) 986-6005