Dr. Bailie proudly sees all patients regardless of insurance plans. However, he is only contracted with specific insurance plans that he feels provide value to their customers. As premiums and deductibles have sky-rocketed in recent years, Dr. Bailie feels that healthcare decisions need to be given back to the patient and physician. Transparency is very important so that you understand your rights and the benefits you deserve from your healthcare insurance.
Because some insurance carriers have made it so burdensome to provide adequate care, Dr. Bailie can no longer be contracted and accept their terms, which contradict his high standards. Some examples of this include limiting rehabilitation after major surgery, denying important imaging tests and requiring unnecessary peer-to-peer reviews with an unqualified employee of the insurance company. There is nothing more frustrating and detrimental to your care than undergoing surgery only to have the results negatively affected by an insurance company’s random decision to limit your post-operative care. Remember, this is ABOUT YOU and YOUR HEALTH, so demand the benefits you deserve.
As a result of recent class action lawsuits filed against several of the insurance carriers for violations of the Federal ERISA Act, many patients have realized that they were unaware of their own insurance benefits. As a result, on your behalf, AzIKS will help you better understand your personal benefits and advocate for covered services so that you are able to get the care you want, need and deserve. In order for us to fully understand your particular benefits, your contract will need to legally be released to us as your medical provider. Please click to download and complete this form: ERISA AOR-DOB. As with our other forms, this may be completed electronically: click the link, download the fillable PDF to your computer, open the document and then fill in the required spaces. You can then sign the form electronically by following the signature instruction in the right column and email it to us OR print and sign the form and send to us via scan/email, fax or hand delivery.
Remember that health insurance companies are FOR-PROFIT. They are publicly traded entities and exempt from anti-trust laws, placing patients and healthcare providers at a huge disadvantage. They can artificially create their own “proprietary” fee schedules and decide whether care is deemed acceptable or unacceptable, regardless of the opinions and recommendations of you and your doctor. Their first responsibility is to their stock shareholders, not to you as the patient. In your insurance contract, it will state “AUTHORIZATION DOES NOT GUARANTEE PAYMENT”.
When patients call to make appointments, the first thing asked is usually “does Dr.Bailie take my insurance/Medicare”. The fact is, Dr. Bailie see patients with ALL INSURANCE PLANS, including Medicare even if he is not contracted with those plans. Here is how that works to enhance patient care and keep patient costs reasonable.
Dr. Bailie has treated hundreds of Medicare patients as a NON-PAR provider since opting out in 2006. This means that he cannot legally accept payment directly from Medicare. Dr. Bailie’s direct fee is not covered.
However, discounted fees are negotiated with you directly because Dr. Bailie does not have to follow burdensome federal regulatory processes. He provides substantial discounts for patient out-of-pocket expenses (often greater than 50%) if certain terms are met, such as payment in full at the time of service.
Please contact his scheduler for an initial consultation fee, including x-ray interpretation.
If you should need surgery, ONLY Dr. Bailie’s surgical fee and assistant fee (which, in total, amount to approximately 10% of the total costs associated with surgery) will not be covered. The larger exenses, such as the facility, anesthesia and any post-operative therapy charges WILL be covered by Medicare. We will discuss this with you before proceeding and you will know your responsibility before scheduling.
Many patients find it very affordable to have care by Dr. Bailie and feel that they are getting excellent value given Dr. Bailie’s reputation and surgical skills. Many times the out-of-pocket expenses are similar or LESS than the required deductible of a private healthcare plan.
Dr. Bailie sees many patients using their OON benefits. Understanding the advantage of these benefits will help you get the most out of your insurance, limiting the carrier from blocking access to proper care. Remember, you pay a much LARGER PREMIUM for plans with Out-Of-Network benefits, compared to small, closed, in-network only plans (HMOs).
Dr. Bailie has carefully chosen his accepted insurance carriers. He is Out-Of-Network, meaning he has NOT accepted the restricted terms of the insurance contract, for carriers which he believes have unfair reimbursement practices and unethically limit their customers’ access to care, making it difficult for a patient and physician to make appropriate healthcare decisions.
This does NOT mean that you will have large out of pocket expenses. In fact, many times, using Out-Of-Network results in nearly the same OR LESS out of pocket expenses, as using In-Network providers, depending upon your specific benefit.
For instance, if surgery is required, because he most often uses In-Network facilities, anesthesiologists and therapists for peri-operative care, only Dr. Bailie’s provider fee may not be covered. The facility fee is the largest expense in healthcare, but you will always have a choice in facility, and should discuss with his surgery scheduler. Insurance reimbursements with OON tend to be larger to facilities and providers, as they are not discounted by contract terms. OON facilities will often REDUCE THE COST TO PATIENTS. Some OON facilities can actually SAVE you money compared to In-Network facilities. The system can be quite confusing and we are here to make sure you clearly understand how insurance works and we are transparent with all fees.
Not every plan has OON benefits, so be sure to obtain a clear BENEFIT SUMMARY from your carrier. If you have Out-Of-Network benefits, you pay a large premium for the power to make your own decisions regarding your healthcare, so don’t be afraid to use them!
Even with insurance plans that do not have OON benefits (such as Aetna) our billing team at Clearsight Billing has been successful in assisting patients file an appeal and we have been paid by the insurance carrier allowing a FULL REFUND of our fees to our patients. We provide all needed information including CPT codes, ICD-10 codes, supporting documents, appeal forms etc and work hand-in-hand with our patients so that they can get the coverage they deserve.
Several insurance carriers were sued in a class action filing by the AMA, many State Medical Societies and some private providers. They were accused because of misleading patients and providers regarding the OON benefits and blatant violations of the ERISA Act, which governs health insurance. Please click HERE to review the ongoing litigation and legal complaint against AETNA. CIGNA and United Healthcare were also sued with United settling the case for pennies on the dollar.
IN NETWORK (IN)
In order to be considered In-Network, doctors must have a direct contract with the insurance carrier. If Dr. Bailie participates in your insurance carrier’s network, this means he has agreed to accept a discount (sometimes up to 80%) in reimbursement and to terms specified in the insurance contract (for example: some contracts do not allow patients to pay out of pocket even for non-covered services).
As a patient, be aware that there are hundreds of actual health plan benefits within each insurance company (United HealthCare has nearly 23,000 types of plans). You may be required to provide a co-pay per visit, and although all patients are required to meet their deductible before insurance will pay, you are often still subject to co-insurance at each encounter. Please ask your insurance carrier for a copy of your BENEFITS SUMMARY so that you are familiar with your specific contract. In addition, please complete the ERISA AOR-DOB form so we can try and obtain further information regarding your insurance benefits. Please note that many plans still refuse to provide the requested information, as they know it will put them at a disadvantage. Although they are legally obligated to provide the information, they often force providers and patients to sue them knowing the cost of doing so is too burdensome. Thus, patients and providers often “just go away”.
Dr. Bailie has also agreed to file insurance claims on your behalf for in-network care and you are only responsible for co-pay and co-insurance at the time of service. We may collect your deductible up front (especially if surgery is required). We then bill your insurance for any balance and you will only be billed if the insurance does not pay.
EXAMPLE: IN-NETWORK vs OON
*Usual and customary procedure fee, SURGEON ONLY: $6000
Insurance contract fee (what insurance pays the surgeon) : $957.34
*FACILITY FEE: $7500
Contracted fee: $2500
Contracted fee: $300
*PHYSICAL THERAPY: $150/visit
Contracted fee: $40/visit
**Patient IN-NETWORK Deductible: $ 3500
Patient would pay the $3500 of all costs FIRST, then any applicable co-pay for each visit to the PT and/or doc before insurance would pay.
OUT OF NETWORK (real case)
*Same fees as above
*Patient pays Dr. Bailie a discounted fee up front (depends on complexity of case and procedure; discount cannot legally be applied if making payments) This case was negotiated at $1,500
*Facility, anesthesia, therapy all covered as IN-NETWORK contract requires
*Dr. Bailie bills insurance his full “usual and customary” fee – $6000 in the case
*Insurance paid $2500 for Dr. Bailie’s fee expecting that he would “balance bill” the patient for the difference of $3500
*Dr. Bailie accepted payment from insurance in full and REFUNDED $1500 to the patient since the insurance paid more than the negotiated fee: NO BALANCE BILL!!
*In some cases, insurance payment may be LESS than the negotiated price. This would lead to the patient paying the difference in what insurance paid and the TRANSPARENT AGREED UPON PRICE. NO SURPRISE BILLS!!
Refund amount will depend on insurance payment: If insurance pays equal to or more than what the patient paid, then the difference or more is refunded and patient often pays Dr. Bailie NOTHING for the surgery – LESS than if IN-NETWORK
Consider that this is your health. Do your homework and research your surgeon as you would any major investment. You deserve the highest quality medical care and receiving treatment from a physician just because they are on your insurance plan network does not mean QUALITY. Make sure they are board certified and subspecialized and perform high volumes of the procedure being recommended. Ask as many people as possible about who you are choosing to provide your care. Interview and see more than one physician if needed. Ask the surgeon about their complication rates and outcomes. YOU MUST BE SELECTIVE.
As Dr. Bailie specializes in revision surgery (over 1/2 of his patients have had an unsatisfactory outcome from surgery performed elsewhere), he knows all too well that many patients may ASSUME that all physicians are “created equal”. Successful surgical outcomes require knowledge, experience AND artful surgical skills, the latter of which cannot always be learned. Dr. Bailie believes that a surgeon is only as good as his/her patients’ outcomes and satisfaction. He is constantly advancing his approach to shoulder and knee problems based on research, experience, patient feedback and self assessment (Dr. Bailie is his own worst critic) in order to achieve excellence. He believes that QUALITY AND VALUE are a must!
Please call 480-264-6995 or email APPOINTMENT@AZISKS.COM to learn more about which plans Dr. Bailie is currently contracted with and schedule an appointment.