AGHS - Physician Billing FAQ

What kinds of insurance does Atlantic General Health System accept?

Atlantic General Health System and its employed providers participate with the following insurance carriers:

Blue Cross Blue Shield (all Carefirst products except BlueChoice) 410-629-6004
Blue Choice 410-629-6010
Blue Cross Blue Shield of Delaware 410-629-6004
Medicare Maryland and Delaware 410-629-6001
Medical Assistance Maryland and Delaware 410-629-6003
Coventry of Delaware (HMO or PPO) 410-629-6002
Tricare and Tricare for Life 410-629-6003
United Healthcare 410-629-6003
Wells Fargo-Perdue 410-629-6003
Cigna 410-629-6003
Multiplan/PHCS please check with your provider prior to your appointment
State managed care organizations
o Priority Partners
o UHC Community Care (formerly AmeriChoice)
o Amerigroup
o Aetna - Maryland
o Medicare
o Open Access

Aetna - Delaware
o No - Medicare

What is the difference between and HMO and PPO?

Most of the time HMOs tend to be group plans rather than individual plans. A HMO requires that you only see its doctors, and that you get a referral from your primary care physician before you see a specialist. They may have central medical offices or clinics or it may consist of a network of individual practices.

Preferred Provider Organization (PPO). PPOs have made arrangements for lower fees with a network of health care providers. PPOs give their policyholders a financial incentive to stay within that network. For example, a visit to an in-network doctor might mean you'd have a $10 co-pay. If you wanted to see an out-of-network doctor, you'd have to pay the entire bill up front and then submit the bill to your insurance company for an 80 percent reimbursement. In addition, you might have to pay a deductible if you choose to go outside the network, or pay the difference between what the in-network and out-of-network doctors charge. Preventive care services may not be covered under a PPO.

What is a third-party administrator?

Third Party Administrator (TPA) is an organization that processes insurance claims. The TPA is not the insurer; they do not pay the claim.

For example, an employer may choose to contract with a TPA for administration of the claims processing for employees and a TPA may administer many aspects of a self- funded health care plan. An insurance company may also use a TPA to manage its claims processing, provider networks, utilization review, or membership functions.

How will my bill be submitted?

The claim is submitted to the insurance and reimbursement is sent directly to the provider if AGHS participates with your insurance.

Participating with the insurance means that you re-assign benefits to the provider, and the provider will accept the allowed amount by your insurance.

What am I responsible to pay when I visit my doctor?

Your insurance plan will probably include a cost sharing feature where you pay a portion of the fee for the cost of medical care after the deductible has been satisfied.

Deductible - A fixed dollar amount that must be paid prior to eligibility for payment of covered services.

Co-Pays - Members pay a fixed dollar amount, such as $20 to visit the PCP, $30 to be treated by a Specialist, and $50 for an ED visit.

Co-Insurance - Members pay a fixed percentage of the cost. In this cost-share, the patient pays 20% and the insurance pays 80% of the allowed amount.

How much is my Medicare deductible?

For the current deductible amount, please check the website.

Why do I have to pay when I have insurance?

If you are covered by a participating insurance, we are contractually obligated to collect any co-pay, co-insurance or deductible from you. Prior to your visit, we verify your insurance coverage and the amount you will be responsible to pay at the time of service.

Medicare patients will pay their deductible amount and co-insurance at the time of service if they do not have a secondary insurance. Patients with a medigap coverage (or insurance that covers their deductibles and/or co-insurance) will not pay at the time of service.

What will I have to pay if AGHS is non-participating with my insurance?

If you are covered by an insurance that is non-participating with AGHS, payment will be expected on the date of service. The front office will provide you with a super bill so that you can submit it to your insurance.

Non-Participating with the insurance means that you do not assign benefits to the provider, and the provider does not accept a discounted reimbursement.

The insurance will reimburse you directly.

My insurance is non-par. Will you sign an agreement to accept this insurance?

You can contact your insurance company and ask if they contract with providers in this area. Letters of interest to participate should be submitted to:

AGHS, 9733 Healthway Drive, Berlin, Md 21811
Attn: Payer Relations Committee

What does in-network provider mean?

A network provider is a physician or group with contractual agreements with insurances which determine the allowed amount the physician may charge. The patient portion of the fee is determined by your insurance plan.

What does out-of-network mean?

An out-of-network provider is one not contracted with a particular health insurance plan. Generally if you see an out-of-network doctor, the insurance company will either pay less or not pay anything for services you receive from out-of-network providers. In addition you may have to pay the difference between what the in-network and out-of-network doctors charge.

What does a contractual adjustment mean?

This is the difference between the amount that the physician charges and what the contractual agreement is with your insurance. The patient is not responsible for this portion of the fee if it is a covered service.

How much of the bill will my insurance company cover?

Questions regarding insurance coverage and benefits should be directed to your employer or insurance company.

Why can’t the AGHS staff tell me what my insurance will cover?

Health insurance is important to all of us, but can be difficult to understand. The benefits, rules, and restrictions are determined by the terms of your policy, as well as the contracts AGHS has with the various insurance carriers. These questions, and others, that are specific to the coverage of your own insurance policy should first be directed to your insurance provider. Insurance contact information will be located on your insurance card, the insurance website or in your policy manual.

Why do I need to bring my insurance card to my appointment?

Your insurance card provides an incredible amount of information needed for billing purposes; such as your membership number, effective date, group number, billing address, type of plan, co-pay amounts and often much more. Once we have the information in our system, we need to review your insurance card in subsequent visits to ensure that our information is current and verify that there have been no changes in your insurance plan. This prevents a lot of billing confusion, and limits the chances that we send you a bill because of incorrect insurance information.

I have insurance, so why am I receiving a bill?

Insurances rarely pay 100% of physician services. The benefits, rules, and restrictions are determined by the terms of your policy.

What do I do if I disagree with how much the insurance paid?

If you disagree with the amount the insurance paid for a claim, contact the insurance company directly.

Can you re-bill my insurance if they did not pay?

We can re-bill a claim within 180 days from the date of service for valid reasons such as data entry errors, inaccurate patient or insurance information. We can rebill your insurance if they made an error, such as processing your claim “out of network” or a data entry error on their part. We can only resubmit a claim if the medical documentation supports the diagnoses and services provided.

What does coordination of benefits mean?

Coordination of benefits (COB) is used to establish the order in which health insurance plans pay claims when a patient has more than one insurance. We bill your primary insurance, then your secondary insurance. When health care benefits are coordinated, the insurance companies share the cost without overpaying.

Can you bill my child’s other parent’s insurance for the visit?

If a patient is under the age of 18, the parent presenting the child for examination is considered the parent responsible for the bill. If we participate with the other parent’s insurance, we would submit the claim. The parent presenting the child for medical treatment would be responsible for the out-of-pocket expense that is due at the time of service.

Why am I getting my bill months after I was treated?

Some insurance plans take up to 90 days or more to pay a claim. The patient is not sent a statement until your insurance has processed your claim.

You billed me for a doctor I did not see! Why?

  • Some insurances require when a patient sees a nurse practitioner or certified physician assistant that the claim is submitted under the supervising physician's name.
  • If you had surgery you may not recall or know the anesthesiologist’s name.
  • A bill may be submitted for the “technical or professional” portion of the services (such as x-rays, EKGs). The bill will have the name of the physician who oversees the facility or has read/reviewed your test or x-ray.

Can I pay my bill online?

Yes, you may pay online. Click here to fill out the form.

Select the correct type of payment from the drop down screen, physician visit fee or hospital charge.

Can I set up a payment plan?

In some circumstances a payment plan can be arranged prior to services.
Please ask to speak with the practice manager at your doctor's office to make payment arrangements.

  • Berlin Primary Care, 410-641-0430
  • Atlantic General Pulmonary, 410-641-9646
  • Townsend Medical Center, 410-289-6241
  • Ocean Pines Primary Care and Women’s Health, 410-208-9761
  • Berlin Women’s Health (Barrett Medical Office Building), 410-629-6870
  • Snow Hill Family Practice, 410-632-3100
  • Pocomoke Medical Center, 410957-6622
  • AGHS Neurology, 410-641-4765
  • AGHS Surgical and Medical Oncology Specialists, 410-629-6888
  • Ocean View Internal Medicine, 302-541-4460
  • AGHS Internal Medicine/Selbyville, 302-564-0001

I have Medicare, why am I asked to sign an ABN for some services?

You are asked to sign an ABN notice before items or services are furnished when the provider believes that Medicare probably or certainly will not pay for some or all of the items or services on the basis of medical reasonableness and necessity. You can make an informed decision whether or not to receive the items or services for which you may have to pay out of pocket or through other insurance. Example: Medicare covers pap tests and pelvic exams once every 24 months, or once every 12 months for women at high risk, and for women of child-bearing age who have had an exam that indicated cancer or other abnormalities in the past 3 years.