How Insurance Works at Manhattan Pain Medicine
One of the most common questions we receive is, “How does insurance work at Manhattan Pain Medicine?”
Manhattan Pain Medicine is an out-of-network practice. This means we do not have direct contracts with insurance companies. However, many insurance plans include out-of-network benefits, and when they do, our team can often submit claims to the insurance company on the patient’s behalf.
Before care begins, our team reviews the patient’s insurance information through a Verification of Benefits process. This helps us understand whether the plan includes out-of-network benefits, whether a deductible or coinsurance may apply, and how the insurance company may calculate reimbursement.
Because every insurance plan is different, patient responsibility can vary. Our goal is to explain the verified benefits, review anticipated costs when possible, and help patients understand important terms such as deductible, coinsurance, allowed amount, fee schedule, and Explanation of Benefits.
Insurance verification is not a guarantee of payment. Final coverage is determined by the insurance company after claims are submitted and processed. Still, reviewing benefits in advance helps reduce surprises and gives patients a clearer understanding of how their care may be handled.
Some services may be self-pay, and some insurance plans may not include out-of-network benefits. If that applies, our team will review available self-pay rates before scheduling or treatment.
If a reimbursement check is sent directly to the patient by the insurance company, our billing team will guide the patient on the next steps. Patients should not endorse insurance checks over to the practice unless specifically instructed. In many cases, payment is made separately through the patient portal or by personal payment method.
Manhattan Pain Medicine is opted out of Medicare. Medicare patients are required to sign the appropriate Medicare opt-out acknowledgment before care. If a Medicare patient has a secondary plan with out-of-network benefits, our team can review whether submission to the secondary payer may be possible.
Our goal is to make the financial side of care understandable, organized, and as transparent as possible, so patients can focus on their evaluation and treatment with clearer expectations.
Verification of Benefits (VOB)
Verification of Benefits
Verification of Benefits, often called a VOB, is the process of checking a patient’s insurance plan before care begins. The goal is to better understand what the plan may cover and what the patient may be responsible for.
During this process, our team may review whether the plan includes out-of-network benefits, whether a deductible remains, what coinsurance may apply, whether authorization or referral rules exist, and how the insurance company may calculate reimbursement.
A VOB is helpful, but it is not a guarantee of payment. Insurance companies make the final decision after a claim is submitted, reviewed, and processed.
At Manhattan Pain Medicine, we use the VOB process to help patients understand their benefits before moving forward, reduce surprises when possible, and make more informed decisions about care.
Learn how our insurance verification process works, what a Verification of Benefits (VOB) can tell you about your coverage, and what to expect before your appointment.
Out-of-Network Benefits
Out-of-Network Care
Out-of-network means Manhattan Pain Medicine does not have a direct contract with the patient’s insurance plan.
This does not always mean insurance will pay nothing. Some plans include out-of-network benefits, which means the insurance company may reimburse part of the cost for eligible services.
In out-of-network care, Manhattan Pain Medicine has a fee for the service. The insurance company then decides what it considers the allowed amount for that service. The plan may apply the patient’s deductible, coinsurance, and out-of-network rules to that allowed amount.
In some cases, the patient may also be responsible for the difference between Manhattan Pain Medicine’s fee and what the insurance company allows or pays. This is why our team reviews benefits in advance and discusses estimated responsibility before care whenever possible.
Learn how out-of-network benefits work, what they may cover, and how our team helps patients understand their insurance and estimate treatment costs.
Deductible
Deductible
A deductible is the amount a patient pays out of pocket during a plan year before insurance begins paying for covered services.
Many plans have separate deductibles for in-network and out-of-network care. This means a patient may have met the in-network deductible but still have a separate out-of-network deductible remaining.
For example, if the out-of-network deductible is $2,000 and the insurance company allows $1,200 for a service, the patient may be responsible for that full $1,200 if the deductible has not yet been met.
A common misunderstanding is that once a deductible is met, all care becomes free. In many plans, coinsurance still applies after the deductible is met.
Learn what an insurance deductible is, how it affects your out-of-pocket costs, and what to expect before starting treatment.
Coinsurance
Coinsurance
Coinsurance is the percentage a patient pays after the deductible has been met.
For example, if the insurance company allows $1,000 for a service and the patient’s out-of-network coinsurance is 30 percent, the patient’s share would usually be $300. The insurance company would typically pay the remaining $700, assuming the deductible has already been met and the service is covered.
The important point is that coinsurance is usually based on the insurance company’s allowed amount, not the full billed amount.
This is one reason two patients can receive the same service but have different insurance payments and different out-of-pocket responsibilities.
Learn what coinsurance is, how it impacts your healthcare costs, and what it means for your treatment and insurance benefits.
Out-of-Pocket Maximum
Out-of-Pocket Maximum
An out-of-pocket maximum is the most a patient should pay in a plan year for covered cost-sharing, such as deductibles, copays, and coinsurance.
Once that amount is met, the insurance company typically pays 100 percent of the allowed amount for covered services for the rest of the plan year.
However, many plans have separate out-of-pocket maximums for in-network and out-of-network care. Also, some costs may not count toward the out-of-pocket maximum, including non-covered services or the difference between Manhattan Pain Medicine’s fee and the insurance company’s allowed amount.
The out-of-pocket maximum is an important protection, but it does not always mean every possible cost disappears. It depends on the plan, the service, and how the insurance company calculates coverage.
Learn what an out-of-pocket maximum is, how it limits your annual healthcare costs, and what it means for your insurance coverage and treatment expenses.
Self-Pay or No Out-of-Network Benefits
Self-Pay
Self-pay usually means one of two things: either the patient chooses to pay directly without using insurance, or the patient’s insurance plan does not include out-of-network benefits.
If a plan has no out-of-network benefits, the insurance company may not reimburse the visit or procedure, even if a claim is submitted.
In that situation, the patient is typically responsible for the full fee, unless a self-pay rate, payment plan, or other approved arrangement applies.
Certain services may also be self-pay even when a patient has insurance. Our team reviews these details in advance whenever possible, so patients understand which services may be billed to insurance and which services may require direct payment.
Learn what to expect if you're paying out of pocket or don't have out-of-network benefits, including how our team helps you understand your costs and treatment options.
Allowed Amount, Fee Schedules, UCR, and EOBs
Allowed Amount and Explanation of Benefits
The allowed amount is the amount an insurance company recognizes for a specific medical service. This amount may be different from the amount billed by Manhattan Pain Medicine.
Some plans calculate out-of-network reimbursement using a percentage of Medicare, sometimes called an MCR-based rate. Other plans use UCR, which stands for usual, customary, and reasonable. UCR is a benchmark the insurance company uses to decide what it considers a reasonable rate for a service in a specific area.
These calculations are not always transparent, and different plans can assign very different allowed amounts to the same service.
After a claim is processed, the insurance company sends an Explanation of Benefits, also called an EOB. The EOB may show the billed amount, allowed amount, insurance payment, deductible, coinsurance, denial reason, adjustments, appeal rights, and the amount the patient may be responsible for.
The EOB is important because it explains how the insurance company processed the claim. Our billing team can help patients review the EOB and better understand what it means.
Learn what allowed amounts, fee schedules, usual and customary rates (UCR), and Explanation of Benefits (EOBs) mean, and how they affect your healthcare costs and insurance coverage.
Insurance & Billing FAQ
Manhattan Pain Medicine is an out-of-network practice, which means we do not have direct contracts with insurance companies.
If your plan includes out-of-network benefits, we can submit claims to your insurance company on your behalf. We do not bill Medicare, Medicaid, Workers’ Compensation, or No-Fault insurance.
Our team verifies your benefits before care whenever possible and reviews your estimated patient responsibility with you in advance.
This estimate is based on the information provided by your insurance company, including out-of-network benefits, deductible, coinsurance, and fee schedule details when available. The final amount is confirmed only after your insurance processes the claim.
A cost-share deposit is an upfront estimated payment collected before or at the time of service.
It is based on what we estimate your insurance may not cover, including deductible, coinsurance, undercoverage, or the difference between Manhattan Pain Medicine’s fee and what your insurance allows. After your claim is processed, your account is reviewed and reconciled.
You may receive a final bill if your insurance pays less than expected, if deductible or coinsurance still applies, if the plan’s allowed amount is lower than the billed fee, or if your insurance sends the reimbursement check directly to you instead of our office.
Your exact final responsibility is known only after the insurance company processes the claim and issues an Explanation of Benefits.
Some out-of-network insurance plans send reimbursement checks directly to the patient.
If this happens, please deposit the insurance check into your personal bank account and submit the corresponding payment to Manhattan Pain Medicine by personal check, credit card, or online payment within 10 business days of the check date.
Please do not sign the insurance check over to our office, because checks issued in the patient’s name cannot be deposited by Manhattan Pain Medicine.
Yes, in some situations.
If Manhattan Pain Medicine is billing your insurance, you cannot also submit the same claim yourself. If you are fully self-pay, our team can provide an itemized bill once the clinical note is signed so you may submit it to your insurance company for possible reimbursement.
Medicare patients cannot submit claims to Medicare because Manhattan Pain Medicine is opted out of Medicare. Patients with secondary insurance may be able to submit to the secondary plan depending on that plan’s rules.
If your plan does not include out-of-network benefits, your insurance may not reimburse care at Manhattan Pain Medicine.
In that case, you would usually be considered self-pay, and our team would review the applicable self-pay rates before scheduling or treatment.
Any verified overpayment will be refunded after your insurance claim fully settles.
While claims are still being processed, credit balances are considered provisional. They may be held for up to six months to allow time for insurance adjustments, corrections, or retroactive changes. Once all related claims are finalized, any remaining credit may be refunded or, upon your request, applied to future visits.
Medication savings programs, sometimes called copay assistance programs, are manufacturer programs that may help reduce the patient’s out-of-pocket cost for certain medications.
These programs may help with deductibles, coinsurance, or copays assigned by insurance for the medication itself. They usually do not cover the provider’s administration fee, and reimbursement is not guaranteed.
For billing questions, please contact billing@manhattanpainmedicine.com.
Our team can help review your statement, insurance payments, Explanation of Benefits, patient responsibility, refunds, and payment options.
