Billing FAQs

1. EPay: You can make a one time payment by using the EPay Code found on your billing statement. The EPay method would allow you to make a payment but will not show your account detail such as e-statements.
2. Fully Hosted: Allows you to create a username and password for future payment purposes. Once your account is created, you can view your e-statements and make online payments.

A “provider-based” or “hospital outpatient” clinic refers to services provided in hospital outpatient departments that are clinically integrated into a hospital. Provider-based billing is a type of billing for services provided in a clinic or department considered part of the hospital. Even though you’re seeing your regular physician in a clinic setting and not actually hospitalized, your visit is billed under the hospital outpatient rather than the physician’s office. When you see a physician in a provider-based clinic, physician and hospital charges are billed separately. You will received two statements for the visit

The clinical integration allows for higher quality and seamlessly coordinated care. Patients benefit because all participating hospital facilities must follow more strict quality standards and offer additional resources for patients and their families. With this change, Emory can work to enhance the services and expand care for patients. Enhanced services would also include additional pharmacist support and other clinical support provided throughout the Health system.

Under this structure, our patients may receive two set of charges on their billing statement as well as on their Explanation of Benefits (EOB).

• One statement for the professional services fee represents charges for the professional services provided by the physician (MD), nurse practitioner (NP) or physician’s assistant (PA).
• One statement for the facility fee represents the costs of operating a building/facility for health care delivery and covers the cost of equipment, utilities, maintenance, supplies and medications administered during a clinic visit. The fee also pays for care by non-physician staff such as nurses, pharmacists, social workers, medical assistants and dieticians, who work for the hospital.

Depending on your insurance policy, you may see the facility fee charge applied to your hospital deductible and/or co-insurance. If you have an annual out-of-pocket maximum, these charges will apply only until you have met that amount.

Please call your insurance carrier directly to clarify the coverage provided by your specific policy using the phone number on the back of your insurance card.

• Accepted Insurance Carriers

Depending on your specific insurance coverage, it is possible that some benefits will differ for services and procedures performed in a provider-based clinic. Since a provider-based clinic is a hospital outpatient department, some patients may have to pay a higher cost because a portion of the billed service is being charged as a hospital charge. The increase in cost is a result of the health plan’s coinsurance and deductible. Patients with a supplement plan are not likely to see much change.

Patient liability is based on the services rendered and the insurance company’s negotiated rate with the hospital. Patient liability is then based on the patient’s co-insurance and deductible amount. Until services are determined including medications, we are not able to generate a cost estimate. Once services have been determined, you may contact 404-686-0260 or email ehc.access@emoryhealthcare.org.

The clinical integration allows for higher quality and seamlessly coordinated care. Your clinical care will not change. You will continue to see your regular doctor and health care team, and continue to receive excellent-quality care. Scheduling appointments and tests will be handled as they have been in the past. Learn more about Emory Healthcare's mission, vision and values in Gold Standard for Health Care.

If patients have billing questions for the Emory Clinic (physician bills) they can call 404-778-7318 or 1-800-511-4443. For hospital billing questions, they can contact our Hospital Patient Financial Services department at 404-686-7041 or 1-800-827-7041.

Federal law requires most health insurance plans to cover routine patient care costs* in clinical trials under certain conditions. Such conditions include:

• You must be eligible for the trial
• The trial must be an approved clinical trial
• The trial does not involve out-of-network doctors or hospitals, if out-of-network care is not part of your plan

Also, if you do join an approved clinical trial, most health plans cannot refuse to let you take part or limit your benefits.

Please check with your Health Plan for specific detailed coverage policy.

Health plans are not required to cover the research costs of a clinical trial. Examples of these costs include extra blood tests or scans that are done purely for research purposes. Often, the trial sponsor will cover such costs.

Plans are also not required to cover the costs of out-of-network doctors or hospitals, if the plan does not usually do so. But if your plan does cover out-of-network doctors or hospitals, they are required to cover these costs if you take part in a clinical trial.

Emory Healthcare has a dedicated Clinical Trials Billing Department responsible for evaluating each charge and determines whether the service or item is covered by a trial sponsor. Those services and items that are not covered by the trial sponsor and are routine patient care costs would be included on a claim for third party payer or patient bill.

“Grandfathered” health plans are not required to cover routine patient care costs in clinical trials. These are health plans that existed in March 2010, when the Affordable Care Act became law. But, once such a plan changes in certain ways, such as reducing its benefits or raising its costs, it will no longer be a grandfathered plan. Then, it will be required to follow the federal law.

Federal law also does not require states to cover routine patient care costs in clinical trials through their Medicaid plans.

Medicare

Original Medicare (Part A and/or Part B) pays for routine costs of items and services in certain covered clinical research studies. Examples of these items and services include:

• Room and board for a hospital stay that Medicare would pay for even if you weren’t in a study
• An operation to implant an item that’s being tested
• Treatment of side effects and complications that may occur as a result of the study Original Medicare won’t pay for:
  • The new item or service that the study is testing unless Medicare would cover the item or service even if you weren’t in a study
  • Items and services the study gives for free (many times the treatment will be provided free by the study sponsor)
  • Items or services used only to collect data and not used in your direct health care (like monthly EKGs for a condition that usually requires only a yearly EKG)

If you’re concerned about paying for services Medicare won’t cover, talk to the study staff and see if they can help.

Commercial

Federal law requires most health insurance plans to cover routine patient care costs* in clinical trials. It depends on whether your plan exist before the Affordable Care Act become law in 2010. Please check with your Health Plan for your plan policy.

Yes. If you’re in a Medicare Advantage Plan (like an HMO or PPO) or other Medicare health plan, you can get the same coverage for clinical research studies as a person in Original Medicare, as described in the previous section. If you join certain covered clinical research studies, Medicare will pay for your covered services as if you were in Original Medicare. This means that your Medicare health plan can’t keep you from joining a clinical research study. However, you should tell your plan before you start a study.

• Learn More

Medicare traditional fee-for service reimburses qualifying clinical trial claims on behalf of the Medicare Advantage. Your provider likely has submitted a claim to Medicare Traditional based on the Centers for Medicare and Medicaid Services (CMS) guidelines. CMS waives the Part A and the Part B deductibles, but the EOB may still include the coinsurance or normal member copays for the incurred types of services. Your Medicare Advantage plan very likely may cover the coinsurance or normal member copays after Medicare Traditional process the claims. Please check with your Medicare Advantage plan for your plan policy.

*Routine patient care costs means the costs of any medically necessary health care service for which benefits are provided under a health benefit plan, without regard to whether the enrollee is participating in a clinical trial.