In Network vs Out of Network
Appalachian Wellness Center PLLC can no longer afford to participate in Blue Cross Blue Shield.
We have never participated in “all” insurance plans. “Participation” means that a medical practice agrees to a reduced rate of compensation for taking care of the customers of any given insurance company as well as other conditions set forth by the insurer. More paperwork is certainly part of those demands–a LOT happens “behind the scenes” that patients are unaware of. These time consuming tasks are not compensated and can drive a small practice like ours out of business trying to keep up to their demands.
Patients have lower out of pocket expenses when they see an “in-network”, “participating” provider. They are still free to have care provided by “non-participating” providers. We’re still pleased to be able to provide you with the care that you need. We’re honored that you’ve chosen us!
Many states have laws that require insurance companies that do not have a “participating/In-Network” provider capable of meeting the needs of those suffering from rare illnesses that the insurance plan must allow it’s customers to see a “Non-participating/Out of Network” physician as if that physician were “Participating/In-Network”.
For Medical Care Outside of Your Insurer’s Network (Non-Participating/Out-of-Network Provider)
North Carolina General Statutes
§ 58-50-56.1. Exclusive provider organizations, exclusive provider benefit plans.
(g) Each insurer shall include a clear statement in any application and any benefit booklets for exclusive provider benefit plans that out-of-network coverage for insureds in the G.S. 58-50-56.1 exclusive provider benefit plan only applies for
(i) emergency services and
(ii) medically necessary covered services when an in-network provider is not reasonably available.
These laws are known as the “Any Willing Provider” clause.
If your insurance company is in a state that does not have this requirement, it doesn’t hurt to ask nicely so that you can get the care you need. Writing to your state representative and senator in your state capital can also help. These are the “powers that be” that regulate insurance companies, often, a simple phone call from their office will change the insurance companies mind. Be sure to ask for a letter from other insurer authorizing treatment by an out of network provider!
The “Any Willing Provider” statute in Georgia is codified under O.C.G.A. 3-24-59.6. This statute requires health insurers to allow any willing physician or other healthcare provider who meets certain credentialing requirements to participate in their network. The law aims to increase competition among healthcare providers and give patients more options when choosing a healthcare provider.
In South Carolina, there is a statute known as the “Any Willing Provider” statute, which is designed to give patients the freedom to choose any licensed physician or health care provider who agrees to the terms and conditions of participation in an insurance plan. However, there is no specific statute number for this law, as it is part of the South Carolina Code of Regulations. The law can be found in Title 69, Chapter 53, Section 105 of the South Carolina Code of Regulations which outlines the requirements for insurance providers to allow any willing physician to participate in their networks as long as certain conditions are met.
- If your health insurance plan does NOT provide access to a “Participating” provider that;
- Accepts the discounted fees mandated by your insurance plan.
- Is able to provide the type of care that you require such as being;
- Trained in Chronic Inflammatory Response Syndrome per the Shoemaker Protocol.
- Is a Lyme-Literate Physician (LLP) capable of diagnosing and treating complex chronic illnesses such as Chronic Lyme Disease and other tick-borne illnesses (TBI).
- One could also make an argument that if numerous practitioners have been unable to adequately diagnose and treat the condition, perhaps because it requires Integrative/Functional Medical Care, then §58-50-56.1.(g) clearly states there are grounds to appeal to the plan to allow access to a non-participating/out-of-network provider in which the patient would pay as if the provider was covered by the plan as a participating/in-network provider.
- Such care must be authorized by the plan for;
- Emergency services and
- Medically necessary covered services when an in-network/participating provider is not reasonably available.
- Write a letter to your health insurance company requesting coverage as required by North Carolina General Statute §58-50-56.1.(g).
- Ensure that you make the insurer aware that you want a letter, in writing stating that such coverage will be provided.
- A phone call should be adequate.
- If not, send a letter.
- If no adequate response or denial occurs…
- Send another letter by certified mail, return receipt requested.
- If coverage is still not approved by your insurer, file a complaint with the North Carolina Department of Insurance.
Although this requires additional effort on your part, there’s no reason for the insurance premiums that you pay to not cover the care that you need. Every state in the US has such a statute as North Carolina General Statute §58-50-56.1.(g).
If you live outside of North Carolina, do an internet search for your state’s “General Statutes” “Health Insurance” “Participating” to help locate the statute for your state.
Similarly, if you live outside of NC, locate the link for your state’s Department of Insurance Complaint Department so that you can file the appropriate complaint in your state.
Another option is to look at your voter’s registration card to determine who your State Representative & Senator are. Contact them in your State Capital and enlist their assistance.
Insurance companies don’t appreciate coming to the attention of those who make the laws!
We accept third party payers including:
- Cigna (except Wake Forest and Duke University).
Note: No longer accepting NC Blue Cross/Blue Shield or NC Medicaid
Please review your policy for more details on your coverage—for instance, some Cigna policies have restrictions such as only being accepted at Duke University System facilities.
All other insurance companies are out of network/Non-Participating.
Prior to your first office visit, please email (cao@AppWell.net) us a copy of your insurance card (front & back). This will allow us to provide a more accurate estimate of your total financial responsibility at your initial visit.
We will collect at the time of the visit any copay or Deductible etc. If you have a high deductible, your insurance does not become effective until the deductible is met. You are responsible for paying your portion at the time of your appointment until you reach your deductible.
NOTE: Not all Medicare supplemental coverage is considered in our network and eligible for coverage.
We will have to contact your Supplemental Medicare Company and find out if your policy is “In-Network/Participating”. Each plan is a little different. Before we call and check it please make sure you have Part B as this is the only type that is acceptable in our office.
We will let you know what to expect from your insurance company.
If you have coverage please make certain you have coverage for Prolonged office visits. If your insurance policy states that they only pay for up to an hour then make sure we make and keep your appointment under the guidelines of your policy. Each and every person’s coverage is different. We do not have the ability to look it up. The patient is ultimately responsible for anything their insurance does not cover.
Out of Network Insurance or Self Pay
Anything not listed above in Network is considered out of network coverage. So we do not accept Aetna, United Healthcare, MedCost, & other states’ Medicaid, That means we will collect a deposit of $500.00 as a deposit (for out-of-network/Non-Participating patients only) for your First Lyme or CIRS appointment. At the time of your first appointment, you will owe the remaining balance of your projected fee prior to being seen. Appointment fees are based on time spent preparing for your visit and during your visit as well as any additional testing deemed necessary. Feel free to discuss with our office staff prior to your appointment if you have any questions. Typically, our fees are $300 for the first 50 minutes patient time and $200 for each subsequent 50 minutes of time. We also bill for the time spent preparing for your visit. We will provide a copy of the paperwork so that you can send it to your insurance company and get reimbursed by your insurance. If they have forms that they use please provide them several days in advance. If they need a copy of your chart then it is your responsibility to go into Patient Fusion and print off a copy and email it to them. Excessive clerical time spent by our staff is also subject to a fee.
No Show / Missed Appointments
All missed initial appointments will be charged at full price for non-rescheduled or non-cancelled appointments.
Please email 2 full business days prior to your upcoming appointment in writing if you need to reschedule your appointment to provide proof of your cancelation at a minimum of 2 full days prior.
All schedule changes must be done 2 full business days prior to your appointment.
There is a $100 charge for missed follow-up appointments.
All no-show visit charges will not be billed to your insurance but directly to you.
Pre and Post appointment time involves creating charts, transposing data, organizing your information, review of other information that may have been sent prior to appointment, while post-appointment work involves medication refills, care coordination, phone calls, Emails & prior authorizations for medications etc. These services take time/money and will be billed according to permitted standards and billing codes used by Medicare, NC Medicaid and 3rd party insurers.
$ 300.00 for the first hour and $200.oo for all additional 50 minutes.
$200 for each additional 50 minutes or $100.00 for each additional 25 minutes.
Nutritional Counseling $50.00 for 50 minutes.
We also provide referrals to trusted practitioners for other services such as mental health counseling, trusted sites for supplements, compounding pharmacies etc.
Your Health Starts Here
Contact us to schedule your appointment today!
Phone: (828) 785-1850
Hours: 9am - 5pm Monday-Thursday