Facts You Should Know About Your PPO
You asked... we listened!

In an effort to provide you with the most current PPO insurance information, we have created a PPO resource guide with frequently asked questions and answers. Sutter Gould Medical Foundation hopes this information will give you better insight for how PPO insurance works. Please be advised that all insurance plans are different. In order for you to have the best knowledge of your plan, we encourage you to call your insurance carrier. Their customer service representatives will be able to answer your questions and give you the most current information about the PPO plan you chose.

Get to know your PPO!

• Most Commonly Asked Questions

• 1. I was told my procedure/test was authorized, why do I have to pay?

  Authorization does not guarantee full payment. “Authorization” simply means your insurance company determined the service medically necessary. The plan you’ve chosen determines what your out-of-pocket cost will be.

• 2. What is the difference between a referral and an authorization?

  Referral: A request from a provider for services.

  Authorization: Approval for the referral from the insurance company for services determined to be medically necessary.
  NOTE: Authorization does NOT guarantee full payment.

• 3. Is there a way I can make payments?

  You can call Sutter Physician Services at 1-866-233-5330 to set up a budget plan with a customer service representative. If you were referred outside of Sutter, you will need to contact the office that is billing you.

• 4. Why didn’t the doctor tell me the cost during my visit? Shouldn’t he/she let me know what is covered?

  Our providers are required to bill only for the service they provide, not according to what a patient’s insurance plan covers. Also, given the amount of different PPO plans that are available, it would be impossible for us to know the benefits of every plan. If you feel your provider has recommended a service or procedure and you are unsure of your benefits for that service, we encourage you to contact your insurance and ask them about your coverage BEFORE having the service scheduled.

• 5. What is the difference between diagnostic and preventive services?

  • Preventive Services are those that prevent disease or injuries.
  • Diagnostic Services are those that determine the identity of a disease or illness.

  Examples of Preventive Services include:

  • 1: To prevent disease or injuries, a physician performs an evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/procedures
  • 2: A screening mammogram
  • 3) A screening pap smear
  • 4: A screening colonoscopy
  • 5: A screening cholesterol panel
  • 6: A vaccine

  Examples of Diagnostic Services include:

  • 1: To determine the identity of a disease or illness, a physician performs an evaluation and management of an individual’s complaint or problem including a medically necessary history, examination, counseling, and ordering of laboratory/procedures
  • 2: a diagnostic blood test
  • 3: a diagnostic radiology test
  • 4: a diagnostic procedure such as colonoscopy to evaluate the problem of bloody stools

  There may be occasions when you present a health problem at the time of preventive visit. There may be an additional charge for this health problem.

  NOTE: To determine what your plan covers, call the member service number located on your insurance card.

6. My insurance company told me you can change the billing code so they can pay for the service. Why can’t you?

Physicians are required by law to accurately document each procedure/office visit. Changing a code in order to have the service covered by a patient’s insurance plan could be fraud according to the American Medical Association Standards for Ethical Coding.

7. Who can I contact to find out what my out-of-pocket expenses will be for an upcoming test / procedure my provider has ordered?

You will need to contact your provider’s office for the billing code for the test or procedure he/she has ordered so you can contact the customer service phone number on your insurance card and ask what your out of pocket costs will be.

8. Does my copay have to be paid at every visit?

Yes, according to the insurance plan you chose, this is the agreed upon amount you must pay.

Call your customer service number on your insurance card for the following information:

• How much your yearly deductible is and how much has been met.
• Why the co-payment for your primary care physician is different from a specialist.
• To find out if a Sutter Gould provider is contracted under your insurance.
• To find out what your covered benefits are.
• To find out what hospital and/or lab facility is contracted by your insurance.

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Insurance benefits are ever-changing and confusing for all of us. At Sutter Gould Medical Foundation we want to partner with you and provide resources and information which will empower us to work together as a team to provide the very best service and health care available. It is equally important that you take the time to learn about your plan benefits through the resources your insurance company provides such as customer service representatives, plan manuals, and company websites. We hope you find this information helpful.