Billing & Insurance
If you have questions about your hospital or clinic bill, please contact the facility at which you received care.
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Hospital bills and health insurance claims can be confusing. We want to help you understand how we bill patients, and get information on financial assistance if you are unable to pay.
Fully Understand Your Insurance Benefits
- To receive full insurance benefits, some health plans require you to go to an "in-network" or "participating provider" doctor or hospital. Call your insurance company to make sure of its conditions. Be sure your Avera hospital or doctor is in its network.
- In an emergency, go to the nearest hospital. Your insurance company may either cover these costs or ask that you go to an "in-network" hospital if it is safe to do so.
- If you choose to go to an "out-of-network" hospital in a non-emergency, you may have to pay a larger deductible or a greater part of your bill. Be sure to know the "out-of-network" rules of your insurance plan.
- Some insurance plans require you to call for approval before you receive certain services, or to tell the plan within a certain time after you are hospitalized. Be sure you know your insurance company's coverage requirements. On elective procedures, always ask both your physician's office and your insurance plan about coverage.
- Obtain any required prior authorizations, submit referral or claims forms, and complete a coordination of benefits when needed. We will assist with pre-authorization for procedures, tests, etc., however it is the patient’s responsibility to make sure that insurance has approved the procedure.
Avera locations accept assignment on Medicare claims. We will complete and file your Medicare claims for you. You will receive an explanation of benefits from Medicare stating what has been paid. Remaining amounts will either be paid by your Medicare supplement, or become your responsibility. At the time of registration, inform Avera staff of any Medicare supplement policies that you have, or other coverage.
Avera has adopted policies and procedures to align with Medicare's regulations on hospitalization. This means that upon admission or in the event of extended hospital stays, patients may be issued a denial of coverage if their condition does not meet Medicare approved criteria for hospitalization. It this occurs, Avera staff will work with patients and families to find other resources to provide the appropriate level of care.
Medical Assistance Programs, often referred to as Medicaid, may be administered by your state or county. If you qualify for these programs it is your responsibility to let our business office know immediately. Evidence of eligibility must be provided on the day of your visit. Medicaid claims must be processed within four months from the date of service. Without this information from you, we are unable to process your claim and will bill you personally.
When You Register at Your Clinic or Hospital
Give complete information when you register at your hospital or clinic, including driver’s license and photo ID, all insurance cards and authorization forms. If you have been cared for at an Avera facility before, let us know approximately when and where.
At registration, you will be informed about how we use your health information to submit your insurance claim. (In Minnesota, we will ask your permission to release your health information to your insurance company.)
After You Receive Services
Avera will bill your insurance company, Medicare or Medicaid on your behalf for payment of medical services. Avera will bill additional insurance payors if you have more than one.
Medicare or your insurance company will send you an "explanation of benefits" that shows information about what is paid, any non-covered, deductible or denied amounts and the balance owed by you.
You will receive regular, easy-to-read statements. These statements show the most current balance owed by your insurance company or due from you. After your insurance pays, Avera will send you a statement to notify you of your balance owed.
Respond promptly to requests you receive from your insurance company. Sometimes, an insurance company needs a response from you to resolve issues related to your account or coverage. The balance owed will become your responsibility if your insurance company:
- Does not make payment within a reasonable period of time (usually 60 days after billing)
- Does not respond to our attempts to resolve payment matters on your behalf
Your Hospital Bill
Your bill shows the charges for all of the services you receive during your stay. Charges fall into two categories:
- Basic daily rate. This includes your room, meals, nursing care and housekeeping.
- Charges for special services. These include items or tests that your physician orders for you such as X-rays or laboratory tests.
Your Separate Physician Bill
You may receive bills from physicians or specialists who diagnose and interpret tests and treatments you receive while in the hospital. Often you do not see these specialists in person. They include pathologists, radiologists, anesthesiologists and others. If you have questions about these bills, call the number printed on the statement you receive from them.
Please make timely payments on your portion of the bill. Payment for your hospital bill is ultimately your responsibility. (Exceptions: approved Medicare, Medicaid, TRICARE and HMO services) At the time of service or discharge, you may be asked to pay deductibles, co-payments or other self-pay amounts due. You may be asked to pay if you do not have insurance coverage for your hospital services. Avera accepts cash, personal checks, debit cards, money orders and certain credit cards. Interest-free extended payment options are available to those who qualify.
The best number to call for questions is the number on your bill. Your physician may order tests or procedures that your insurance company does not cover. In these cases, check your health plan handbook or call the telephone number on your insurance card for more information.
Business office or billing staff can help you with payment issues and questions about:
- Insurance benefits
- Hospital charges
- Payment options
- Application for financial assistance programs
- Language translation if needed
Avera billing and business office staff can answer many of your questions. Avera also has financial counseling services available. There is no charge for an initial consultation, and for a nominal charge of $75 per year, our financial counselor will manage your medical billing file and will contact Medicare and/or your insurance company on your behalf. If you need help understanding or managing your medical bills, please call 605-322-6444. In Sioux Falls, a financial counselor is available Monday through Friday 8 a.m. – 4:30 p.m. (except holidays) at Plaza 2 on the Avera McKennan campus.