Billing FAQ's

I have health insurance, so why did I get a bill?

Sansum Clinic sends out bills after your insurance company has processed the bill and made payment to us. The amount you owe represents your balance after the insurance portion has been paid. The amount can be deductible, copays, or co-insurance. It may also be the amount that your insurance company has determined to be non-covered, not medically necessary, or cosmetic.
If you have an amount owed that you feel is in excess of what you should owe, first compare it to your insurance EOB. If the amounts are the same, contact your insurance company for an explanation as to why you owe that amount. If your EOB shows you owe less, please contact the Sansum Clinic billing office for an explanation:
(805) 681-1760
(800) 281-4425
Billing@sansumclinic.org
Hours: Monday - Thursday: 8:00 am - 5:00 pm, Friday: 8:00 am - 12:00 pm

I have HMO insurance and my designated primary care physician (PCP) does not practice at Sansum Clinic. Will services I receive at Sansum Clinic be billed to me or to my HMO?

Prior to seeing a Sansum Clinic physician, you must obtain a referral from your primary care physician (PCP). For your convenience, we first submit a claim to your insurer following the service we provide. However, financial responsibility must be arranged directly between you and your HMO insurer (See also "I have health insurance. Why did I get a bill?"). Once we have heard from your HMO, the remaining balance, if there is any, will be billed to you.

My insurance plan covers Colonoscopy Screening, why did I receive a bill?

If your physician finds a polyp during a colonoscopy screening, it is very important that it is removed at the time of the procedure. Removing polyps helps to prevent colon cancer. However, in doing so, the examination no longer meets the definition of a “screening” and we must accurately code the bill to represent the services that were performed. It must now be coded as “diagnostic”.

Often insurance companies will not pay for the colonoscopy as a screening and you have a larger copay or deductible than you anticipated. When you call the insurance company to determine why, they will often tell you that your doctor “coded it wrong”. This is not correct, since it is illegal for us to code a claim only for the purpose of getting an insurance payment.

Your insurance company should cover your exam when you come in for a screening, whether it is a negative screening or a polyp is found. The purpose of the examination is early detection, and when the exam accomplishes what it was intended to do, it is inappropriate for the insurance company to then deny the proper payment.

Had the doctor not removed the polyp, only then could we have called it a screening, and billed/coded it that way. However, that would defeat the purpose of the exam.

Coverage is based on a member’s individual health benefits and may vary from payer to payer. We advise you to call your insurance company to confirm your benefits for prior to your appointment.

My insurance plan covers Preventive and Physical Examinations. Why did I receive a bill for services provided during this visit?

The “preventive or wellness” code includes your medical history and other questions related to your overall health and wellbeing. It is a service to evaluate and maintain your health and is focused on preventing future illness. It includes a stable or chronic condition(s) that requires no additional work-up or treatment modification.

The “problem-oriented examination” is related to the history of a specific problem or illness, and medical care focused on assessing and treating the problem or illness.

However, during your visit the physician may need to work-up and/or treat a new condition or make treatment modifications for an established condition that want reviewed.

When this occurs, Sansum Clinic is legally required to submit a bill to your insurance company that most accurately describes all the services that were provided. As a result, the charges for a visit that include both a “preventive” and a “problem-oriented” service must be broken into two distinct codes.

This may result in an additional charge for the visit that you thought was going to be covered with no deductible or coinsurance/copay by your insurance company.

Coverage is based on a member’s individual health benefits and may vary from payer to payer. We advise you to call your insurance company to confirm your benefits for prior to your appointment.

What treatments are covered by my insurance?

Insurers' coverage and restrictions vary widely and are subject to change by your insurance company. It is important that you check your insurance policy or consult your insurance plan administrator to ascertain both which services are covered and what requirements need to be met for the treatment to be covered by your specific insurance plan.

When should I call to check the status of my bill?

You may call the Patient Accounts/Billing department at any time. However, in order to allow enough time for your insurance to pay and for the clinic to make adjustments/ and/or corrections, please wait at least two weeks after receiving your EOB. You should also call if your insurance or any of your billing information changes.

When should I expect to make my co-payment?

Co-payments need to be made prior to obtaining treatment. Please take care of your co-payment when you check in with registration for your appointment. Co-payments can be made by check, MasterCard, Visa, or in cash.

Which insurance plans does Sansum Clinic accept?

Our insurance plans page details the HMO and PPO plans which we currently accept.