Frequntly Asked Questions

How does insurance-based billing works and what is fee-for-service (FFS)?

This is when your health insurance plan covers a portion of the costs associated with medical services. When you visit a healthcare provider, you are responsible for paying the fee or copayment specified in your insurance plan for each service received. The insurance company then pays their portion of the eligible expenses directly to the provider. This is also referred to as fee-for-service model.

A fee-for-service medical practice is a healthcare model where medical providers are reimbursed for each individual service they provide. Patients or their insurance companies pay a specific fee for each medical service rendered, such as office visits, televisions, procedures, tests, or treatments.

At Avicenna Direct Care we are able to serve both insurance-based patrons and membership-based. However, we believe that primary and preventive care is better served in a membership-based way. This is why many of our membership-based patron have insurance but do not use it for their primary care as it is more costly and provides less value than opting for membership-based offerings.

What services are covered by fee-for-service insurance?

Fee-for-service insurance typically covers a wide range of medical services, including office visits, diagnostic tests, laboratory work, surgeries, hospitalizations, prescription medications, and specialized treatments. The coverage depends entirely on your specific insurance plan and its associated benefits. Please note that insurance coverage does not imply that there will not be any out of pocket expenses for you. Please familiarize yourself with any out of pocket expenses that insurance plan may have - copays, deductibles, co-insurance, family max etc.

How much will I have to pay for each service?

The amount you have to pay for each service depends on your insurance plan's fee schedule and your individual plan details. This can include copayments (fixed amount per service), coinsurance (percentage of the service cost), and deductibles (amount you must pay before insurance coverage kicks in). Reviewing your insurance plan or contacting your insurance provider directly can provide more accurate information on your costs. Amounts vary state to state, insurance to insurance, plan to plan. Full coverage with zero out of pocket costs is rarely ever the case.

Do I need to submit claims to my insurance company?

In a fee-for-service insurance model, the healthcare provider typically submits claims on your behalf to the insurance company for services rendered. However, it's always important to review your insurance plan's guidelines to understand if there are any specific procedures or requirements for claim submission.

Are there any limitations or exclusions in fee-for-service insurance?

All insurance plans have certain limitations or exclusions. These can include specific procedures or treatments that may not be covered, certain experimental treatments, cosmetic procedures, or services. It's essential to review your insurance plan's policy or contact your insurance provider to understand any limitations or exclusions that may apply.

How can I determine if a service is covered by my insurance?

Reviewing your insurance plan's coverage details or contacting your insurance provider directly can help you determine if a specific service is covered.

Do you take my insurance?

The best way to know this is to call your insurance and find out. Please call your insurance carrier andassk if Dr. Lubna Malik, Dr. Bilal Mannan, Dr. Hyasmine Charles or Avicenna Direct Care comes up as IN NETWORK for your plan. This is the BEST way to get the answer you need. It is the responsibility of the patient to check prior to coming in for an appointment. You are welcome to come to our practice even if we don't take your insurance as a cash paying patient or enroll in our membership plan. Many of our patients prefer this over insurance as it is often a more cost effective option.

Why did I get charged for a copay and/or deductible when my insurance covers well visits?

As per the American Medical Association and the Center for Medicare and Medicaid Services (www.CMS.gov), if any abnormalities or pre-existing problems are discovered and addressed during a preventative exam, it can be separately billed to your insurance. For example, if a urine dip or Hemoglobin done at your visit comes back abnormal, there may be further work up and planning. From a preventive aspect it is important to run these tests as they can help us detect diseases earlier and start the treatment ahead of times. Abnormalities such as heart murmur, abnormal weight or blood pressure, delayed milestones, or behavioral issues are examples of issues that may come up in a well visit, which would then be billed as additional work up. These are just a few examples of a multitude of possible issues. A "sick" and a well visit may BOTH be billed in this case.

If I think there is an error on bill, is it ok to wait until my next appointment to bring it up?

No. Please call the office as soon as you get the bill if you think there is an error, or you have any questions about the bill.

What does "Maximum Benefits Reached" mean on my statement?

The term "Maximum Benefits Reached" on your statement typically refers to the point at which you have utilized the maximum coverage or benefits allowed under your insurance plan for a specific period. It indicates that you have reached the maximum limit or cap for certain services or categories of services.

Insurance plans often set limits on the amount they will pay for certain services, treatments, or procedures within a specific time frame, such as a calendar year. Once you reach this maximum benefit amount, the insurance company may no longer provide coverage for those particular services, and you become responsible for any additional costs. For example, an insurance carrier may limit the number of well visits or sick visits per year and once that is reached any additional doctor visits will be the patient's responsibility.

We understand such caps can be very frustrating and difficult for many people, especially children, larger families or those with complex conditions. This is why we recommend membership-based care for such patrons to avoid unnecessary bills and limits on care.

Do you do sport's physicals, school forms and other medical form?

Yes we do. However if you are using your insurance then your insurance may not cover such a visit as it is not a well-visit or a 'sick' visit. Many insurances do not. We charge $75 dollars per for any visit that requires physical and a form associated with it. All forms require 7 days of processing time. All urgent physicals and associated forms are charged at $125 / visit.

**please note these charges are only for insurance-based patrons and not members.

Why is my deductible higher for some visits than others?

Depending on the complexity of the visit, a higher visit code may be used.

Frequntly Asked Questions

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