Billing & Insurance
Insurance plans that we participate with include the following:
Please note: If you are a participant of an HMO, you need to have one of our doctors listed as your OB/Gyn doctor along with your primary care (internist) doctor. If this is not done, your claim could be rejected and you will be responsible for the bill.
We are providers for the Women’s Health Partnership (Monroe County) and other NYS Healthy Women Partnerships. For information on screening services in other counties, visit the DOH website.
If you have any questions about the insurance plans we participate in, you may reach our Billing office at 585-244-4360. We will be happy to speak with you.
Avoid surprises in your medical bills:
- The “No Surprises Act” is federal legislation that addresses billing when patients get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center.
- Federal law requires all providers to provide a good faith estimate to uninsured individuals or individuals who choose not to have their insurance billed for all medical items and services.
- New York State law: You are protected from surprise billing under New York State law
Your Rights and Protections Against Surprise Medical Bills
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such
as a copayment, coinsurance, and a deductible. You may have other costs or have to pay the entire
bill if you see a provider or visit a health care facility that is not in your health plan’s network.
“Out-of-network” describes providers and facilities that have not signed a contract with your health
plan. Out-of-network providers may be permitted to bill you for the difference between what your
plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This
amount is likely more than in-network costs for the same service and might not count toward your
annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you cannot control who is
involved in your care—including when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
1. Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing
amount (such as copayments and coinsurance). You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition unless you give written
consent and give up your protections not to be balanced billed for these post-stabilization services.
You are also protected from balance billing under New York law, including for emergency services in
hospitals, including inpatient care following emergency room treatment.
2. Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections.
You are never required to give up your protection from balance billing. You also are not required to get care out-of-network. You can choose a provider or facility in your plan’s network.
You are also protected from balance billing under New York law when you are treated by an out-of-network doctor at a participating hospital or ambulatory surgical center in your health plan’s network.
Additionally, if you have health insurance coverage provided by an insurer or health maintenance organization (HMO) you are protected from balance billing when a participating doctor refers you to
a non-participating provider.
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and
deductibles that you would pay if the provider or facility was in-network). Your health plan will
pay out-of-network providers and facilities directly. - Your health plan generally must:
o Cover emergency services without requiring you to get approval for services in advance
(prior authorization).
o Cover emergency services by out-of-network providers.
o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
o Count any amount you pay for emergency services or out-of-network services toward your
deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed
Department of Health and Human Services
(877) 696-6775
Your rights under federal law
Department of Health and Human Services
or
New York’s Department of Financial Services
(800) 342-3736
email: surprisemedicalbills@dfs.ny.gov
Your rights under New York’s law
Department of Financial Services website
Your Right to Recieve a Good Faith Estimate
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need to give patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services.
- You have the right to receive a Good Faith Estimate for the total
expected cost of any non-emergency items or services. This includes
related costs like medical tests, prescription drugs, equipment, and
hospital fees. - Make sure your health care provider gives you a Good Faith Estimate
in writing at least one business day before your medical service or
item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service. - If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
Questions
OR more information
about your right to a
Good Faith Estimate:
visit www.cms.gov/nosurprises
or call our Billing Department
at (585) 244-3430
How to Receive a Good Faith Estimate
Please have the description or CPC code of the procedure you would like the estimate for
Contact WGCA Billing Department
Call: (585) 244-3430
Monday – Friday 7:30 am to 4:30 pm
About Insurance
Individuals who have recently had a baby or surgery, and will be out of work for some time as a result of these conditions, may be eligible for New York State Disability (NYSD). Most employers are required by state law to provide insurance coverage for these Disability Benefits. Some patients may also have private disability policies that provide benefits after childbirth or surgery.
Steps to Take
To file for Disability Benefits, you will need to obtain the necessary forms from your employer’s Personnel Office or HR Department. Disability claim forms usually require information and signatures from you (the patient), your employer (including recent wage information), and your doctor (Women Gynecology and Childbirth Associates, PC). Please bring these forms to our office at least one week before your due date or surgery date. Please do not give these forms to your doctor; you may leave them for the Disability Secretary at the Front Desk.
As a general rule, disability forms should not be submitted more than two weeks before your disability begins (surgery date, or deliver date) to avoid denial by the insurance company. A denial may delay the receipt of your benefits and may require that you resubmit your forms. If your claim is denied, please contact our office immediately so that we can work with your insurance company to resubmit updated forms, if necessary.
Filling Out the Forms
You must fill out the portion indicated for “Claimant Information.” – Part A. If you are given a standard DB-450 disability form, question #7 must be answered, or your disability benefits may be delayed. Download and print a copy of the DB-450, if you need one.
For pregnant patients, once you have delivered your baby, you should receive a supplementary form from your insurance company. Please bring or send that form to our office so we can update the information we have already given them (i.e. your delivery date and type of delivery). Additionally, if you had a baby boy and he had a circumcision, please call or send a note to our office with his full name, insurance company including contract number, and the name of the subscriber on the contract.
Please contact your insurance company to add your baby to your contract. Most insurance companies require that your baby be added t within 30 days of birth, to pay claims for these services. If you do not add your baby to an insurance policy, you may be responsible for the baby’s bills and your claims may be denied.
Other Information
In the event your disability needs to be extended, a note from your doctor will be mailed to you, which you must then forward to your employer. You need to be aware that if your insurance company does not agree with our medical opinion for the extension, you may not be paid.
Please note, your sick time is not considered to be part of your disability. Physicians can not give an excuse for sick time extensions.
The insurance company typically covers:
If your company employs over 50 full-time employees you may want to inquire about your rights under the Family Medical Leave Act (FMLA).
If you have any questions, please call our office and ask to speak with the secretary who handles Disability insurance. We are here to help.
Office Policies
Late Arrival Policy
If you arrive more than 15 minutes after your scheduled appointment time you may be asked to reschedule your appointment for a different date and time. We make every effort not to disrupt the scheduled time of our other patients.
CoPays/Deductibles
The physicians at Women Gynecology and Childbirth Associates would like to inform you that if you discussed anything “above and beyond” a “routine” annual examination with your provider, or if you had other services (for example ultrasound, DXA scan, or a provider consultation during a diagnostic exam), there may be an extra co-payment applied to your claim, as required by your insurance company.
An annual examination consists of a complete breast exam, heart and lung check, gland check, pelvic exam, and pap smear, and rectal exam if indicated.
What to expect at your Annual Exam
Providing time to discuss other issues during an annual exam is an opportunity that we gladly give to our patients. Our providers feel that our patients should not be inconvenienced by having to make multiple trips to our offices to discuss these other issues.
