DO YOU STILL NEED HEALTH INSURANCE IF YOU JOIN DR. WOJNICKI’S DPC PRACTICE?
YES! Please do not cancel your health insurance if you choose to enroll in this practice. The monthly membership fee applies ONLY to Dr. Wojnicki’s care (primary, outpatient care) of yourself and your family. While the majority of all health care recipients use nearly 100% primary care, you still should have coverage to help you pay for specialist visits, when necessary, surgery, hospitalization, especially costly tests/studies, and complex procedures.
However, this being said there may be ways to SAVE a significant amount of money on insurance premiums by taking a high deductible plan with a health savings account or a catastrophic plan.
You may currently have a major medical plan with high premiums and a low deductible. If you are primarily using your plan to obtain primary outpatient care, consider changing your plan to a higher deductible plan. Chances are good that you could save much more in premiums each month than what it would cost to be a member of my DPC practice. If you needed to see a specialist, have surgery, or got hospitalized, you may save so much in premiums that you’d be able to pay that higher deductible with those savings and still come out ahead or at least break even. If you don’t require any of these higher levels of care, you’d just have more money in your pocket at the end of the year. Please talk to your insurance agent/broker or human resources representative to review all of your options and take some time to work through the math before making a final decision.
If you are young and very healthy, you may consider a “catastrophic” plan, which for most people will have premiums of $40 or less per month. These plans, while very inexpensive, have very high deductibles (typically ~$10,000) and only cover extreme conditions like heart attacks, cancer, and major trauma, but often, if you need non-catastrophic, yet non-primary care healthcare, you will save so much in a year by not paying premiums for a major medical health plan that you could pay out of pocket for those other services and STILL come out ahead. You may have to figure in the cost of the Obamacare Shared Responsibility penalty, if it is not repealed, but there are many cases in which you can be exempted from this penalty (talk to your accountant to be certain). I strongly urge you to discuss all of your options with your insurance agent/broker to see if you can DPC work for you.
CAN I SUBMIT CLAIMS TO MY INSURANCE FOR REIMBURSEMENT OF FEES FOR LABS, RADIOLOGY STUDIES, OR OFFICE VISITS?
(Medicare recipients, skip to the Medicare question in the FAQ section.) This will depend on your particular insurance and there are far too many for me to be able to answer for each of them. In some insurances (more likely HMOs rather than PPOs), the doctor ordering a test or a medicine must be “in network” in order for an insurance company to pay anything toward that service. By the nature of a DPC clinic, the doctor is always “out of network” for ALL insurance companies. For most labs and most meds, if you want to submit a claim for reimbursement, you’d have to obtain them through mainstream pharmacies and labs, rather than directly through the DPC clinic. This means you would be charged retail or allowable rates for these services. Odds are that you will pay less out of pocket by obtaining them directly through the DPC clinic than your responsibility would be with insurance, but if you’d like to obtain them outside and submit to your insurance for reimbursement, you are welcome to. However, I can not make any financial guarantee about your success in getting them covered.
Office visits can not be submitted to insurance for reimbursement. First, because the visits are not billed individually but rather a benefit of the membership fee payment, the insurance is unlikely to associate that fee or some proration of it to a particular visit encounter.
However, MUCH MORE importantly: in order for you to get a visit claim approved by yourself, your insurance company will require “codes” from the doctor. There are codes for your diagnosis (over 67,000 from which to choose) and codes for the visit “level” itself (which takes a relatively large amount of time to calculate). Additionally, the insurance will likely require a copy of the doctor’s note, which must include an inordinate amount of extraneous information to justify the “codes” which you are submitting. The significant time burden of figuring out the codes and the unnecessarily long visit notes are EXACTLY why I have chosen the DPC model. I want to spend nearly all of my time talking to you, getting to know you, and most of all, listening to you. This is the essence of what I believe a good doctor is! It is decidedly NOT the doctor who is best at filling out paperwork, pleasing insurance companies, or cramming in 40 patients a day (200 a week). Spending the enormous amount of time it would take to complete the necessary paperwork for my patients to submit for claims that may be denied anyway would destroy the entire environment I am working to create in my practice.
CAN I SUBMIT FOR CLAIMS ON SPECIALIST VISITS IF THE SPECIALIST TAKES INSURANCE?
In most cases, yes. If you have a PPO, you can “self refer” to specialists, so even when I (or any other doctor) refer you to a dermatologist (or any other specialist), it is really only a professional recommendation. Nothing regarding your insurance billing changes whether a PCP refers you or you just find a specialist yourself through your insurance’s website and make an appt with them.
HOWEVER, if you have an HMO insurance plan, you MAY need to have your in network primary care physician refer you to the specialist. Because I will be out of network for your plan, the specialist’s office MIGHT NOT be able to bill your insurance for that visit if I am the one referring you, and you may be asked to pay the full amount of the bill. In most cases, the specialist’s office will know this in advance and they will ensure that the proper referral has been made before even granting you an appt. Even still, this is something you should clarify with your insurance plan or agent prior to enrolling in my family practice.
WHAT IF I HAVE TO GO INTO THE HOSPITAL?
If you just need an ER visit, and then get sent home from the ER, you will see the attending Emergency doctor and use your own insurance (or out of pocket funds) to pay for that visit. If you get admitted to the hospital, either for 23 hr. observation or a full stay, this will also be paid for with your insurance (or self pay). While staying in the hospital, your primary doctor will either be an “on-call” primary care physician for the ER, or what is known as a “hospitalist”. Hospitalists are providers (usually physicians) who exclusively care for hospital inpatients when the patients’ own PCP does not carry hospital privileges. Hospitalists will communicate with me regularly during your hospitalization so I am updated on your care and condition. However, while a hospitalist may ask my opinion about your care, I will not have the authority to make final decisions about your care while you are hospitalized. If you have a chronic medical condition that causes you to be hospitalized frequently, it is important that you consider the above facts before deciding to commit to being a member of my practice.