Medical Insurance Information

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Cardiology involves office visits, diagnostic testing, and sometimes hospital-based procedures. The same plan can cover each of those differently. A little work before your visit prevents most billing surprises.

Call our office to confirm we participate with your specific plan before you come in. Bonita and South San Diego: (619) 585-0476. Redding and Northern California: (530) 433-5427.

Verify Coverage Before Your Appointment

Do not rely on a plan name alone. Insurers sell many products under one brand, and networks differ between them. Two people with cards from the same company can have very different coverage.

Call the member services number on the back of your card. Ask for a reference number for the call. Then call our office so we can verify from our side.

What to Have Ready When You Call

• Your member ID number and group number
• The plan name exactly as printed, including any suffix such as HMO, PPO, EPO, or Advantage
• The subscriber's name and date of birth, if the policy is not in your name
• Our practice name and address, so they can check network status
• The specific test or procedure name, and the symptom or diagnosis prompting it

That last item matters. An insurer answers very differently about an office visit, an echocardiogram, and a cardiac catheterization. Ask about the exact service.

In-Network Versus Out-of-Network

In-network means the practice has a contract with your plan. Rates are pre-negotiated, and you generally pay your plan's normal copay, coinsurance, and deductible.

Out-of-network means no such contract exists. Your plan may pay a smaller share, apply a higher separate deductible, or pay nothing. Some plans, particularly HMOs, cover out-of-network care only in an emergency.

Network status can change from year to year. Confirm it each plan year.

Referrals Versus Prior Authorizations

These are two different things, and cardiology often involves both.

A referral comes from your primary care physician and authorizes you to see a specialist. HMO and many Medicare Advantage plans require one before a cardiology consultation. PPO plans usually do not. Without a required referral, the visit may be denied outright.

A prior authorization comes from your insurer and approves a specific test or procedure before it is performed. Advanced cardiac imaging, nuclear stress testing, CT angiography, and most catheterization-based procedures commonly require one. Routine office visits and basic ECGs usually do not.

Prior authorization takes time. Allow several business days, longer if the insurer asks for additional records.

Questions Worth Asking Your Insurer

• Is this practice in network for my specific plan?
• Do I need a referral from my primary care physician?
• Does this test or procedure require prior authorization?
• What is my remaining deductible for this plan year?
• What is my copay or coinsurance for a specialist visit, and for diagnostic testing?
• Is there a separate facility fee if the service is done at a hospital?

Medicare and Medicare Advantage Are Not the Same

Original Medicare, Parts A and B, generally does not require a referral to see a cardiologist. Part B typically covers medically necessary cardiac testing after your deductible, and you owe coinsurance unless a supplement plan covers it.

Medicare Advantage, or Part C, is a private plan. It must cover what Medicare covers, but it sets its own network, referral rules, and prior authorization requirements. Those rules often look more like a commercial HMO. Treat an Advantage plan as a commercial plan when you call.

What to Expect on Your Bill

For a diagnostic test done in our office, such as an ECG, echocardiogram, or treadmill stress test, you will usually see one bill from the practice. It may list a technical component for performing the study and a professional component for interpreting it.

For a hospital-based procedure, such as an angiogram, angioplasty, or stenting, expect more than one bill. The hospital bills a facility fee. The physician bills separately for professional services. Anesthesia and radiology may bill on their own. Each bill is processed against your benefits independently, so several statements for one procedure is normal, not an error.

Coverage questions are easier to answer than to guess at. Call the office before your visit. See also bill payment options and our locations.