University of Pennsylvania Health System

Patient Insurance

As we strive to provide quality care, we must be mindful of insurance and payment issues. Health care organizations across the country are instituting new procedures to assist patients with the management of their health insurance and out of pocket expenses. We hope this brochure will assist you in understanding your insurance responsibility and our relationship with your insurance carrier.

Insurance

The University of Pennsylvania Health System participates with many medical insurance plans. It is important to understand that your insurance policy is an agreement between you and your insurance carrier. We will submit the claim on your behalf, however that is not a guarantee of payment of the claim. Should your claim be rejected or only partially paid, your insurance company should send you an explanation of benefits. Ultimately, the fees are your responsibility. If we do not participate with your insurance plan, payment is expected at the time of service.

Coordination of Benefits

If both you and your spouse are employed and have insurance coverage through your employers, YOUR policy is your primary coverage. According to insurance regulations, your spouse's policy provides secondary coverage.

Payment

Co-pays, deductibles, co-insurances and fees for non-covered services are expected at the time of your service. A $12.00 administrative fee will be assessed if the co-pay is not paid at the time of service. For your convenience we accept cash, personal checks, Visa, MasterCard, American Express and debit cards.

Health Maintenance Organization (HMO) Plans

  • HMO insurance plans may require a referral from a primary care physician prior to you obtaining services for specialty care. As a patient, you are responsible for securing referrals from your primary physician prior to making an appointment to see a specialist.
  • If you arrive for an appointment with no referral you may be asked to:
    • Contact the primary care physician to obtain the referral
    • Reschedule your appointment
    • Pay the estimated cost of the service prior to seeing the physician
  • HMO insurance plans also require that testing such as laboratory work, X-rays, and physical/occupational therapy be completed at specific sites. As the patient, it is your responsibility to know which site you must use for tests and services. You may obtain this information through your primary care physician's office, or your health insurance company's member services department.

Other Insurance Plans & Agreements

  • Non-Participating Referral (NPR)
  • Out of Network (OON)
  • Point of Service Out of Network
  • Point of Service Plans (POS)
  • Preferred Provider Organization (PPO)

Point of Service and Preferred Provider plans usually offer a network of physicians and hospitals that the member must select from when receiving health care. Members receive maximum benefits if they choose in-network providers. Members may also choose to "self-refer" to an Out of Network provider but a higher co-payment may be applied and the plan may require higher deductibles and/or co-insurance amounts.

If you have chosen to use these options, please be aware that your financial responsibility for co-pays and/or co-insurance may be significantly higher. If we do not participate with your insurance carrier, we will schedule an initial physician appointment for you for the limited purpose of providing an evaluation only. That visit will be considered a consultation only and is a "one-time" appointment with the physician.

We will require that you speak to a financial counselor prior to scheduling additional services. Our financial counselor will provide you with an estimate of the treatment plan cost. Should you elect to have the recommended services, diagnostic studies or other testing at one of our facilities, a deposit equal to 50% of the estimated total must be paid prior to the service.

You may wish to have such treatment or tests performed by another provider who is a participating provider in your insurance carrier's network. If you choose to do so, we will work with you to forward copies of your medical records to the other provider.

If your insurance plan states that it will only make payment to you (the patient), you will be required to pay in full for all services rendered.

The University of Pennsylvania Health System provides financial counseling services to patients regarding their ability to pay for services. If you are uninsured, have concerns about your account or have other questions concerning your insurance coverage, please contact the financial counseling department at 215-349-5300 or 1-866-615-8535.