Office visits

Key takeaways:

• Doctors can bill for both a wellness exam (preventive) AND an office visit (non-preventive) when health concerns are discussed during the visit.
• The visit type can impact cost based on if you’re a new patient or established patient and complexity. Your Benefit Amount adjusts accordingly. Check your Benefit Amount in Care search.
• Where you see your doctor impacts cost (not quality). Find a provider who doesn’t charge a facility fee so you can save.
• The provider fee is just one component of your bill, and there may be other costs to your visit. Be sure the itemized medical invoice contains a full list of all procedures, tests and services obtained.
• In non-emergent situations, always shop for labs and imaging.

Your primary care office visit benefits:

Wellness exams (preventive care) are to review your overall health, prevent illness, and identify risks early.

• Skip the deductible (if applicable – check the Member Portal)
• You will only be responsible for any amount above the Benefit Amount

If you discuss a health concern or condition during your wellness exam, your provider may code and bill the appointment as an office visit (diagnostic or sick) and you may incur additional charges.

• May be subject to the deductible depending on your plan
• You will be responsible for any amount above the Benefit Amount

Unplanned procedures during planned visits will be subject to the deductible and you will not be responsible for any amount above the Benefit Amount when you submit a pre-bill.

In addition to the provider’s fee, there may be other associated costs:

• Facility fee (Hospitals/hospital groups commonly add a facility fee on top of provider’s charge).
  • While your plan provides a separate Benefit Amount for this fee, find a provider who does not charge a facility fee to save.
• Labs and imaging
  • Except in emergency situations, do not get labs and imaging at your provider's office without shopping around.
• Vaccines
  • Preventive vaccines are covered at cost. The portion of the bill related to your vaccine(s) and vaccine admin fees will be covered at cost.
  • Elective vaccines (such as travel vaccines) are also covered at cost but are not considered preventive and are subject to any applicable deductible.
• Ancillary services (other tests and procedures)
  • These types of service can be difficult to shop– call Member Care to help you.
• Procedures
  • Submit a pre-bill so you’re covered for unplanned procedures during planned visits.
    

Did you know?

You will always have the option to receive care within the Benefit Amount, meaning without balance billing. More on when to engage the Sidecar Health pre-bill process here.

Sample scripts

DESCRIBING SIDECAR HEALTH TO PROVIDERS

"My insurance works differently than traditional insurance. I’ll pay you directly in full. You can treat me like a self-pay patient and provide me with an itemized medical invoice. Then I’ll work with my insurance company on the back-end so you don’t have to."

GETTING PRICING FROM EXISTING OR NEW PROVIDERS

"Can you provide the self-pay price for an office visit, including any incremental fees (such as facility fees, test, labs) that I could expect? It's important I understand the cash-pay total for my visit ahead of time so I can choose a provider that charges in the range of my insurance company reimburses. I will pay you directly in full for the visit, but I will need an itemized medical invoice."

ASKING PROVIDER TO SEND LABS TO QUEST DIAGNOSTICS OR LABCORP

"My insurance has a direct payment agreement with Quest Diagnostics and Labcorp* so I would like my labs sent directly to either provider. When sending, mark me as a Sidecar Health member and include my member ID: XXXXXX before sending the samples."

ASKING PROVIDER FOR LAB REQ FORM TO SHOP FOR LABS AND IMAGING

• My insurance works differently, they pay fixed Benefit Amounts for each service and I have the ability to shop for labs and imaging.
• I will have to pay the difference when the lab or imaging facility charges more than my plan’s Benefit Amount so I’d like to find the lowest cost.
• Can you please provide a lab/imaging requisition so I can get the labs myself at an outside lab and send the results to you?

More questions? Your Member Care team can’t wait to answer them. Chat with a real human on our website or at 855-282-0822. TTY: 711  

*Sidecar Health does not utilize a network of providers. External websites and information on healthcare providers, including cost and quality information, is provided for convenience and informational purposes and is not an endorsement or guarantee of pricing, quality, or availability of the provider. Contact the provider for pricing and availability. Sidecar Health bears no responsibility for the accuracy, legality or content of any external websites or for subsequent links from an external sit.