Rothman Orthopaedics: Navigating Insurance Coverage for Your Care

Rothman Orthopaedics, a leading provider of orthopedic care, understands that navigating insurance coverage can be a complex and often frustrating experience. This article aims to demystify the process and provide clarity regarding the insurance plans accepted at Rothman Orthopaedics locations. So, let’s get straight to the point: Rothman Orthopaedics participates with a wide range of insurance plans, including major national and regional carriers. However, specific coverage can vary greatly depending on your individual plan, location, and the services you require. It is ALWAYS recommended that you verify your specific coverage details with your insurance provider before receiving care.

Understanding Insurance Acceptance at Rothman Orthopaedics

The landscape of healthcare insurance is ever-evolving, with new plans and provider agreements constantly being updated. While Rothman Orthopaedics strives to maintain comprehensive coverage for its patients, it’s crucial to understand the nuances involved.

Factors Influencing Insurance Coverage

Several factors determine whether your insurance will cover services at Rothman Orthopaedics:

• Type of Insurance Plan: Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Point of Service (POS) plans all have different rules regarding in-network and out-of-network coverage.
• Specific Insurance Carrier: Different insurance companies have different agreements with Rothman Orthopaedics. Even within the same company, different plans may have different coverage levels.
• Location of Rothman Orthopaedics Practice: Rothman Orthopaedics has multiple locations, and insurance participation can vary by location.
• Specific Procedure or Service: Some procedures may require pre-authorization from your insurance company, while others may not be covered at all.
• Referral Requirements: Some plans, especially HMOs, require a referral from your primary care physician (PCP) before you can see a specialist like an orthopedic surgeon.

Proactive Steps for Verifying Coverage

To avoid unexpected medical bills, it is HIGHLY recommended that you take the following steps before seeking treatment at Rothman Orthopaedics:

1. Contact Your Insurance Provider: The most reliable source of information about your coverage is your insurance company directly. Call the member services number on your insurance card and inquire whether Rothman Orthopaedics (and the specific physician you plan to see) is in-network for your plan.
2. Provide Specific Information: When contacting your insurance provider, be prepared to provide your policy number, the name of the Rothman Orthopaedics physician you plan to see, and the specific procedure or service you are seeking.
3. Inquire About Pre-Authorization Requirements: Ask your insurance company if pre-authorization is required for the specific services you need. If so, understand the process and ensure that it is completed before your appointment.
4. Understand Your Cost-Sharing Responsibilities: Clarify your deductible, co-pay, and co-insurance responsibilities. This will help you estimate your out-of-pocket costs.
5. Contact Rothman Orthopaedics’ Billing Department: You can also contact Rothman Orthopaedics’ billing department directly to confirm insurance participation and discuss payment options.

Types of Insurance Commonly Accepted

While it’s impossible to list every single plan accepted, here are some of the major insurance carriers that Rothman Orthopaedics typically participates with:

• Aetna
• Blue Cross Blue Shield (various plans)
• Cigna
• UnitedHealthcare
• Medicare
• Medicaid (in some locations and for specific programs)

Important Note: This list is not exhaustive, and coverage can vary within each carrier. Always verify your specific plan details.

Frequently Asked Questions (FAQs)

Here are some frequently asked questions to further assist you in navigating insurance coverage at Rothman Orthopaedics:

1. How do I find out if Rothman Orthopaedics accepts my insurance?

The best way to confirm is to contact your insurance provider directly and ask if Rothman Orthopaedics and your specific doctor are in-network. You can also contact Rothman Orthopaedics’ billing department.

2. What should I do if Rothman Orthopaedics is not in my insurance network?

If Rothman Orthopaedics is out-of-network, you have several options:

• Out-of-Network Benefits: Check if your plan offers out-of-network benefits, which may cover a portion of the cost.
• Negotiate Cash Price: Inquire about the cash price for the services you need and compare it to your potential out-of-pocket costs with your insurance.
• Single Case Agreement: In some cases, Rothman Orthopaedics may be able to negotiate a single case agreement with your insurance company. This is more common for specialized or complex procedures.
• Consider an In-Network Provider: Explore other orthopedic providers within your insurance network.

3. Does Rothman Orthopaedics accept Medicare?

Yes, Rothman Orthopaedics generally accepts Medicare. However, it’s important to confirm that the specific physician you are seeing accepts Medicare assignment.

4. Does Rothman Orthopaedics accept Medicaid?

Rothman Orthopaedics accepts Medicaid in some locations and for certain programs. Coverage can vary, so it’s crucial to verify your specific plan and location details.

5. What is a referral, and do I need one?

A referral is an authorization from your primary care physician (PCP) that allows you to see a specialist. Some insurance plans, particularly HMOs, require a referral. Check your insurance plan details or contact your insurance provider to determine if a referral is necessary.

6. What is pre-authorization, and why is it important?

Pre-authorization (also known as prior authorization) is a requirement from your insurance company for certain procedures or services. If pre-authorization is required and not obtained, your claim may be denied. Always verify if pre-authorization is needed and ensure that it is completed before your appointment.

7. What if my insurance claim is denied?

If your insurance claim is denied, you have the right to appeal the decision. Contact your insurance company and Rothman Orthopaedics’ billing department to understand the reason for the denial and the steps required to file an appeal.

8. What if I have a high deductible?

If you have a high deductible, you will be responsible for paying the full cost of your medical care until you meet your deductible. Discuss payment options with Rothman Orthopaedics’ billing department, such as payment plans or financing options.

9. Does Rothman Orthopaedics offer financial assistance?

Rothman Orthopaedics may offer financial assistance programs to eligible patients. Contact their billing department to inquire about available options and eligibility requirements.

10. What is the difference between a co-pay, co-insurance, and deductible?

• Co-pay: A fixed amount you pay for a specific service, such as a doctor’s visit.
• Co-insurance: A percentage of the cost of a service that you are responsible for paying.
• Deductible: The amount you must pay out-of-pocket before your insurance coverage kicks in.

11. Can I use my Health Savings Account (HSA) or Flexible Spending Account (FSA) to pay for services at Rothman Orthopaedics?

Yes, you can typically use your HSA or FSA to pay for eligible medical expenses at Rothman Orthopaedics. Check with your HSA or FSA provider to confirm eligible expenses.

12. What information should I bring to my appointment regarding my insurance?

Bring your insurance card and a valid photo ID to your appointment. If required, also bring your referral and any pre-authorization documentation.

In conclusion, while Rothman Orthopaedics strives to accommodate a broad range of insurance plans, it’s ultimately your responsibility to verify your specific coverage details. By proactively contacting your insurance provider and Rothman Orthopaedics’ billing department, you can ensure a smooth and financially predictable healthcare experience.