Explanation of Billing
Effective Date: January 2024
We strive to provide you with high-quality care while ensuring transparency and clarity regarding our billing practices. Below is important information regarding billing, insurance requirements, and when you can expect to receive a bill.
Billing Rates
For Occupational and Physical Therapy:
At Solace and Sage, we bill each therapy treatment CPT code at $35 per unit, and each evaluation code is billed at $150. These charges have been carefully determined to align with industry standards and ensure affordable and competitive pricing for our clients. Our billing rates are in line with the recommendations provided by Fair Health Consumer, a reputable resource for healthcare cost information (https://www.fairhealthconsumer.org).
For Services and Charges not covered by Medicare and/or Medicaid: In-Home Mobile Visits for Services not covered by insurance:
One hour minimum of $105 for private pay mobile visits.
Next Step Consulting Case Management and Certified End of Life Doula services: $105 per hour Preventative Home Safety Assessments not covered by insurance: $400 (Includes assessment of home and full report with Accessibility Ratings which measure the safety and capability of the home environment.)
Financial assistance for services not covered by Medicare and/or Medicaid is dependent on availability of funding for those living at or below 250% of the poverty level. Solace & Sage offers a sliding scale to help cover the cost of our services, equipment and/or contractor labor charges for those enrolled in programs.
Insurance and Medicare Billing Requirements:
Solace and Sage accept various payment options, including Medicare, Medicaid, and private pay (cash/check/credit card). We work closely with the payors to ensure compliance with their billing requirements and guidelines. You must inform us of any and all changes of health care coverage. Failure to do so may result in denial of coverage by your insurance company.
In-Network
If we are in-network with your health plan, we will submit the claims to your health plan on your behalf and your health plan will send payment directly to us. If your health plan denies payment of our claims, in whole or in part, you are responsible for paying any and all unpaid amounts upon receipt of invoice. You also agree that if any payments are sent to you despite your assignment of benefits to us, you will promptly forward the funds and explanation of benefits/payment.
Insurances we are Credentialed with (In Network): TX Medicare and TX Medicaid
Out of Network
If your insurance allows out-of network claims, we will bill your health plan for our services directly and await payment from your health plan. You agree that if your health plan does not honor the assignment and sends payment to you, you will promptly forward the payments to us. You further agree that if your health plan denies payment of our claims, in whole or in part, you are responsible for paying any and all unpaid amounts upon receipt of invoice.
Private Pay
Private Pay Services are available for clients without insurance or for those that choose not to bill insurance, except for services covered by Medicare and Medicare Advantage Plans. We are required to bill Medicare for services that are skilled and medically necessary. Medicare Advantage plan requirements depend on the type of plan. Private pay services are available to Medicare beneficiaries if the service provided is no longer skilled and medically necessary.
We offer a discounted private payment rate when clients pay the day of service in exchange for the prompt payment and the reduction in administrative work/time since we do not have to file claims or obtain pre-authorization. This prompt payment discount is offered to clients who do not have insurance or who choose not to use their health plan benefits (except for Medicare beneficiaries as noted above).
If we are in-network with your health plan, our prompt payment rate may be less than the in-network rate that we have negotiated with your health plan. If you choose to take advantage of our discounted private payment policy, you understand that we will not submit a claim to your health plan and you agree that you will not submit our claims or statements to your health plan in an attempt to get reimbursed for our services. If you choose to pay privately initially and later want to switch to using your health plan, you understand that the fees for our services may be higher and you will no longer be entitled to our discounted private pay price. Your ability to switch to using your health plan benefits may also be limited by your health plan’s requirements for pre-authorization or other policy limitations.
Estimated Costs after Prompt Pay Discount (not billed to insurance by Solace and Sage):
Estimated Cost of Private Pay Initial Evaluation: $191 (1 unit evaluation/3 unit treatment)
Estimated Cost of 1 hour Private Pay Treatment Session: $105
Estimated Cost of 45 min. Private Pay Treatment Session: $79
Insurance Claims and Billing Timeline
Insurance claims are billed daily to your insurance carrier. The processing time for these claims typically ranges from 30 to 60 days. However, please note that additional processing time may be required if your insurance carrier requests further information or denies the initial claim. In such cases, an appeal process may be initiated, which could further delay your billing.
Receipt of Billing Statements
You will receive an invoice if there is a balance remaining after your insurance company has paid for the covered services. Billing statements are generated once insurance has processed the claims and determined the patient's responsibility. For insured patients, statements are generated after insurance processing. For uninsured patients, statements are generated as soon as the charges are billed to your account during your normal billing cycle. The status of your account will be clearly indicated on each statement.
Understanding Billing Amounts
Please be aware that the prices listed on the billing statements are the amounts billed to your insurer. However, the actual amount you are required to pay out-of-pocket may vary. Providers are often reimbursed at rates lower than the charges. Commercial insurance clients may have negotiated rates, while Medicare and Medicaid clients have reimbursement rates determined by federal and state governments.
Reasons for Delayed Billing
If you receive a bill several weeks or months after the services were provided, it is because we process and send billing statements after payment is received from the insurance carrier. The time required for this process depends on how long it takes to receive a response from your insurance carrier. Additionally, if your insurance carrier denies the initial claim, we may initiate an appeal to secure payment for the services provided, which can further delay your billing.
Understanding Your Insurance Coverage
It is essential to familiarize yourself with the coverage, deductible amount, co-insurance and co-pay requirements of your specific insurance plan. We cannot predict which services will be covered by individual health plans. Some plans may limit payments to "usual, customary, and reasonable payment." To obtain coverage information, please consult your employer, insurance agent, or refer to the details provided by your insurance plan. For Medicare beneficiaries, you can find information on Medicare benefits at your local Social Security office or online at https://www.medicare.gov/.
Coinsurance/deductible
If you have a coinsurance or deductible which has not been met, we estimate the coinsurance/deductible amounts based on the insurance information provided when insurance verification is completed. Since this is an estimate, you may have a refund or balance due.
Insurance Coverage Verification
Solace and Sage provides insurance verification as a courtesy to our clients. Solace and Sage cannot guarantee the accuracy of this information. It is the responsibility of each client to be knowledgeable about their insurance coverage. Your insurance coverage is a contract between you and your insurance company and you are responsible for knowing the level of coverage.
We are committed to creating an environment that values diversity, fosters respect, and ensures equal access to healthcare services for all individuals. If you have any questions or need further information regarding our explanation of benefits policy, please do not hesitate to contact us.
Mailing address: P.O. Box 824 Dripping Springs, TX 78620
Call: 512-651-0341
Email: info@solaceandsage.org
Site: www.solaceandsage.org