Does My Insurance Cover Advanced Care by Wound Care Specialists?

Good to know: We're a specialist

Wound Care Specialists is a specialty practice. That means your plan's specialist copay applies to our visits, not the copay you pay at your primary care doctor. Your specialist copay is usually printed on the front of your insurance card. If you can't find it, the member services number on the back of your card can tell you.

What insurance do you accept in my state?

Here are the insurance plans we can bill today, by state. We add plans often, so if you don't see yours, call us anyway.

Why do you accept more plans in some states than others?

A few reasons, and none of them are about us being picky:

• The network is full. Some insurance networks aren't accepting new providers right now.
• The plan doesn't cover our area. Some plans are only offered in parts of a state we don't serve yet.
• Approval takes time. Every insurer has to approve our group, and often each provider, state by state. In our newer states, we're still earlier in that process.

Our goal is to work with as many plans as we can.

What if my insurance isn't on the list?

Contact us anyway. Let us know which plan you have, and we'll look into whether we can participate with it. Some plans may already be in process.

Note: Self-pay options are reviewed case by case.

How do you check my coverage before the first visit?

When a referral comes in, our team checks your insurance eligibility. Then, the night before each visit, our system checks it again automatically. If anything has changed, we'll know before we see you.

If you switch plans, like during Medicare's open enrollment period from October 15 to December 7, let us know so we can check your new plan.

Will I have to pay out of pocket for my wound care?

Most patients owe a copay or coinsurance. What you owe depends on your plan. Here's what we typically see.

A regular visit (no procedure). If your plan has a copay, you'll owe your specialist copay. For specialists, we typically see copays between $50 and $80. Check the front of your insurance card for yours.

If your plan doesn't have a copay, you'll owe your coinsurance instead. Original Medicare is the most common example. It has no copay, and most commonly you'd owe 20% of the Medicare-approved amount.

A visit with a procedure. Some visits include a procedure, like debridement (carefully removing unhealthy tissue so the wound can heal). For those, you may owe your copay and possibly coinsurance too.

When do I pay my copay? We collect copays at the time of your visit. Usually, someone from our team calls you the day before to remind you about your appointment and take your copay over the phone.

Do I need supplemental insurance (like Medigap) to avoid out-of-pocket costs?

It can help. Medigap (also called a Medicare supplement) is a plan you buy from a private insurer that works alongside Original Medicare. It picks up some or all of the costs Medicare doesn't, like that 20% coinsurance. It doesn't work with Medicare Advantage plans.

When a patient has Original Medicare plus a supplement or other secondary insurance, we typically see them owe nothing for our visits. The one thing that usually isn't covered is the Medicare deductible. Most supplements and secondary plans don't pay it unless your policy specifically includes it.

What can make one wound care visit cost more than another?

With good coverage, the difference from one visit to the next usually isn't dramatic. What changes the cost is the care your wound needs that day.

• A procedure. A visit with a procedure like debridement can mean coinsurance on top of your copay.
• Skin substitutes. These advanced treatments are the only thing we bill separately from the visit itself, and they need approval from your insurance first. We use them when the wound is ready for them, not by default. If you're facing a higher-cost treatment like a skin substitute, financial assistance may be available. Call our billing team to talk it through.
• Medical necessity. Insurance pays for the care your wound actually needs. Our providers document why each treatment is needed, which helps your claim go through.

Who pays for wound care supplies?

Supplies we use during your visit are included. There's no extra charge for them.

If your wound needs dressing changes between visits:

• If you have home health, your home health provider supplies them.
• If you don't have home health, we'll send an order so you can get the supplies at home. They're billed under your plan's DME (durable medical equipment) benefit, so what you owe for them depends on your plan.

Will I get a bill from anyone other than Wound Care Specialists?

For our visits, no. Your bill for wound care visits comes from Wound Care Specialists.

The only time you might get a bill from another company is for:

• Lab work
• Radiology, like an X-ray or other imaging
• Medical supplies or equipment (DME) ordered for use at home

Do I need a referral or prior authorization?

Referral. Usually not. You can refer yourself, or your doctor or another provider can refer you. The exception is an HMO plan, which requires a referral from your primary care provider. Many Medicare Advantage plans are HMOs, so check your card or call your plan if you're not sure.

Prior authorization. Regular visits don't need one. We only need prior authorization for two things: care for veterans through the VA, and skin substitutes. When it's needed, we handle it for you.

What if I can't pay my bill all at once?

Payment plans are available. Call our billing team at 704-626-2639 and we'll work it out with you.

Questions about a bill, your coverage or what you might owe? Our billing team is glad to help.

Email our billing team at patientbilling@thewoundspecialists.com.