Health Insurance
In-Network Coverage
We are currently in-network with PPO plans for Aetna, Cigna, and Medicare FFS (not Medicare Advantage). If we are not currently in-network with your insurance plan, we can provide you with a Superbill to submit to your insurance as an out-of-network provider (Anthem, Blue Cross, Blue Shield, etc).
Folks can sometimes be concerned regarding increased cost with out-of-network providers, however are often surprised by the affordability, and find having the right healthcare provider to be worthwhile. (See below for more detailed explanation).
Health insurance can be confusing, but understanding key terms and how it works will help you make the most of your coverage. Below is a guide to help you navigate the basics of health insurance, including important terms like deductibles, out-of-pocket maximums, copays, and what’s covered during a general physical.
Folks can sometimes be concerned regarding increased cost with out-of-network providers, however are often surprised by the affordability, and find having the right healthcare provider to be worthwhile. (See below for more detailed explanation).
Health insurance can be confusing, but understanding key terms and how it works will help you make the most of your coverage. Below is a guide to help you navigate the basics of health insurance, including important terms like deductibles, out-of-pocket maximums, copays, and what’s covered during a general physical.
CASH PAY PRICING
Monthly Membership / $100
For uninsured or out of network folks looking for regular access to a healthcare provider, Membership Options include $100 / monthly for unlimited access (within reason).
If we are in-network with your insurance plan, or have Medicare, we are prohibited from offering you our membership plan.
Additionally, we have negotiated discounted rates on laboratory services and diagnostic imaging to make healthcare more affordable.
*Initial ADHD consultations are not eligible for the $100/month unlimited membership due to the time-intensive nature of the visit (over 2 hours including documentation). The initial consult is $385. However, follow-up ADHD visits may be covered under the membership or paid individually.
If we are in-network with your insurance plan, or have Medicare, we are prohibited from offering you our membership plan.
Additionally, we have negotiated discounted rates on laboratory services and diagnostic imaging to make healthcare more affordable.
*Initial ADHD consultations are not eligible for the $100/month unlimited membership due to the time-intensive nature of the visit (over 2 hours including documentation). The initial consult is $385. However, follow-up ADHD visits may be covered under the membership or paid individually.
99213 / $125
Short visit (about 20 minutes) for established patients. Best for single-issue check-ins like one med refill, brief follow-ups, or quick concerns.
99214 / $175
Longer visit (about 30 minutes) for established patients. Best for managing multiple conditions, adjusting treatment plans, or refilling medications for more than one issue.
99205 / $250
Extended session for mental health, gender-affirming care, or opioid use disorder. Ideal for patients needing extra time or starting care in these areas.
ADHD Consult / $385
A formal ADHD diagnosis requires at least two appointments. This initial consult includes a 90-minute evaluation and over 30 minutes of documentation review and charting. The total cost for this first visit is $385 for cash-based or out-of-network clients. I can provide a superbill for you to submit to your insurance.
Due to the time-intensive nature of this visit, the initial ADHD consult is not eligible for my $100/month unlimited membership plan. However, follow-up appointments may be eligible for the membership or can be paid per visit.
Botox
Clinic: $12 / unit
Mobile (near 90046): $13.50 / unit
Migraine: $1500 for cash pay (155 units)
Mobile (near 90046): $13.50 / unit
Migraine: $1500 for cash pay (155 units)
Dysport
Clinic: $4 / unit
Mobile (near 90046): $4.75 / unit
Mobile (near 90046): $4.75 / unit
PRP Injections
Clinic: $400
Mobile (near 90046): $500
PRP for two people: $700
PRP Bundle: Four sets of injections $1200 (must use within 12 months, $400 discount)
Mobile (near 90046): $500
PRP for two people: $700
PRP Bundle: Four sets of injections $1200 (must use within 12 months, $400 discount)
Trigger Point Injections
$75 injection fee
Labs
Ordered via LaboratoryAssist for cash / cost savings.
General: Complete blood count (CBC), Complete metabolic panel (CMP), A1C (Diabetes), Cholesterol: ~35.
Gender:
CBC, CMP, Total Test: ~64
CBC, CMP, Total Test, Estradiol: ~100.
General: Complete blood count (CBC), Complete metabolic panel (CMP), A1C (Diabetes), Cholesterol: ~35.
Gender:
CBC, CMP, Total Test: ~64
CBC, CMP, Total Test, Estradiol: ~100.
Key Health Insurance Terms
Deductible
A deductible is the amount you must pay for healthcare services before your health insurance begins to cover costs. For example, if your deductible is $1,000, you must pay $1,000 out-of-pocket for medical services before your insurance starts covering a portion of the costs.
- Example: If you visit the doctor and the cost is $200, and you haven’t met your deductible, you’ll pay the full $200. Once you reach your deductible, your insurance will begin sharing the cost of services with you.
- Some health insurance plans the deducitble does not apply to primary care services if the provider is in-network. Please check with your insurance prior.
Out-of-Pocket Maximum
The out-of-pocket maximum is the most you will pay in a policy period (usually a year) for covered healthcare services. Once you reach this limit, your insurance pays 100% of covered services for the rest of the policy period.
- Includes: Deductibles, copays, and coinsurance count towards your out-of-pocket maximum.
- Does Not Include: Premiums (the monthly fee you pay for insurance) do not count towards the out-of-pocket maximum.
In-Network Providers Copay
A copay is a fixed amount you pay for a specific healthcare service, such as a doctor’s visit or a prescription, with an in-network provider. Copays are usually due at the time of service.
- Example: Your health insurance might require a $20 copay for a primary care visit and a $50 copay for a specialist visit.
Co-Insurance
Coinsurance is your share of the costs of a healthcare service, calculated as a percentage of the total cost of the service, after you’ve met your deductible. Sometimes coinsurance varies between in-network and out-of-network providers.
- Example: If your coinsurance is 20% with an in-network provider and the total cost of a service is $100, you will pay $20, and your insurance will pay the remaining $80. If your coinsurance is 30% with an out-of-network provider, you will pay $30 and your insurance will pay $70. If seeing an out-of-network provider, typically you will pay for your healthcare services in total up-front, and then you will submit the Superbill to your insurance for reimbursement.
Important Notes
Deductibles Must Be Met: Before your insurance covers any portion, you must pay your annual deductible. Deductibles vary widely between plans, so check with your insurance for specifics.
Annual Exams: Some plans fully cover annual exams, even if the deductible hasn’t been met. Contact your insurance to confirm.
Coverage Varies: Final reimbursement depends on your insurance company’s contracted rates and your specific policy terms.
Annual Exams: Some plans fully cover annual exams, even if the deductible hasn’t been met. Contact your insurance to confirm.
Coverage Varies: Final reimbursement depends on your insurance company’s contracted rates and your specific policy terms.
Why Choose Be Well Berlin?
- Affordable Rates: We strive to keep our fees economical to ensure access to quality care.
- Transparency: We provide upfront pricing and can assist you in understanding your insurance coverage.
- Comprehensive Care: Our team focuses on patient-centered care to meet your unique needs.
Need Assistance?
If you have questions about out-of-network billing, contact us or your insurance provider for more details. We're happy to provide superbills (detailed invoices) to help you claim reimbursement from your insurance.
Disclaimer: The examples provided are estimates and actual reimbursement will depend on your insurance's contracted rates and coverage. Please consult your insurance plan for final costs and coverage details.
Disclaimer: The examples provided are estimates and actual reimbursement will depend on your insurance's contracted rates and coverage. Please consult your insurance plan for final costs and coverage details.
What's Covered During a Routine Physical
The Basics
Most health insurance plans fully cover preventive care, including an annual general physical, without requiring you to pay a copay or deductible. This is part of the Affordable Care Act (ACA) requirement for preventive services.
Common services covered during a general physical include:
Important Note: If you discuss new or ongoing health problems during your physical, those additional services may not be covered as part of the preventive visit, and you may have to pay a copay or coinsurance for them.
Common services covered during a general physical include:
- Routine blood pressure, height, weight, and body mass index (BMI) checks.
- Routine vaccinations (flu shot, tetanus booster, etc.).
- Screenings for common conditions such as cholesterol, diabetes, and certain cancers.
- Counseling on healthy lifestyle choices.
Important Note: If you discuss new or ongoing health problems during your physical, those additional services may not be covered as part of the preventive visit, and you may have to pay a copay or coinsurance for them.
Medical Necessity and Insurance Coverage
Key Points
Health insurance companies often determine whether a service is covered based on whether it is considered “medically necessary.” This means that the treatment must be deemed essential to diagnose, treat, or prevent a medical condition.
Important Points About Medical Necessity:
Important Points About Medical Necessity:
- Varying Definitions: Different insurance plans may have different criteria for what they consider medically necessary. For example, some plans may only cover treatments like trigger point injections if they are done in conjunction with physical therapy.
- Service Limits: Even if a treatment is considered medically necessary, some insurance plans may impose limits. For instance, some plans may only cover a maximum of 4 trigger point injections per year.
- Denial of Coverage: If an insurance company does not consider a treatment medically necessary, they may deny coverage. In these cases, patients have the option to pay out-of-pocket (cash) for the service if they believe it will help improve their condition.
- Appealing a Denial: Patients can appeal an insurance company’s decision if they believe a service was wrongly denied based on medical necessity
How Medical Billing Works
Step 1: Receiving Services
When you visit a healthcare provider, the provider records the services they performed. This includes office visits, procedures, and any tests or screenings you received.
Step 2: Submitting a Claim
The healthcare provider submits a claim to your insurance company. The claim includes details of the services provided and their costs.
Step 3: Insurance Processes the Claim
Your insurance company reviews the claim to determine:
- Whether the services are covered under your plan.
- How much of the cost is covered by insurance.
- How much you are responsible for paying (e.g., copay, coinsurance, or deductible).
Step 4: Explanation of Benefits (EOB)
After processing the claim, your insurance company will send you an Explanation of Benefits (EOB). The EOB details:
Important: The EOB is not a bill. It’s a statement explaining what your insurance paid and what you may need to pay.
- The services you received.
- The amount billed by the provider.
- The amount covered by your insurance.
- The amount you owe.
Important: The EOB is not a bill. It’s a statement explaining what your insurance paid and what you may need to pay.
Step 5: Paying Your Bill
If you owe any remaining amount after insurance (e.g., a copay, coinsurance, or because you haven’t met your deductible), the healthcare provider will send you a bill. Always compare the bill with the EOB to ensure accuracy before paying.
Out of Network Provider / Coverage
Out of network coverage varies, most PPO plans typically cover 50-80% of out of network providers. Assume your insurance covers 70% of the allowed amount after the deductible for out of network providers. Below is an example of what you might pay for a visit, depending on your insurance’s allowed amount, assuming you have met your deductible, and the allowed amount is equal to or greater than our fee schedule.
Service: New Patient (60 min)
Service: New Patient (30 min)
Service: Follow-Up (30 min)
Service: Follow-Up (20 min)
Service: Psychotherapy Add-On (16–30 min)
Let’s say your insurance has a lower allowed amount for a level of service 99213, which is $100. At the time of your visit, you would be billed for the cost of the service. Afterwards you would be provided with a Superbill to submit to your insurance. Your insurance has an allowed amount for a 99213 of $100, and insurance covers 70% of the allowed amount, so you would be reimbursed from your insurance of $70. In this situation, your cost for that visit would of totaled $55.
One important factor to note is that medical billing for the level of service is based on the medical complexity of the evaluation. Determining medical complexity is quite complicated and involved, and a 20 minute appointment could easily be either a 99213 or a 99214 depending on the overall medical complexity involved. A simple and often accurate explanation is a 99213 is one stable medical issue that requires a prescription (simple medication refill for one condition). A 99214 is often appropriate for two stable medical conditions that require a prescription, or a chronic medical condition that is not adequately controlled (treatment adjustments etc) or exacerbated. Additionally, let’s say other factors of your health contribute to the medical decision making, this can contribute to medical complexity (typically in situations like these it will increase the medical complexity from a 99213 to a 99214. 99215 are rarely billed in medicine except for established patients where the time for all of the care for that day exceeds 40 minutes).
Unfortunately, health insurances keep their fee schedules and allowed amounts private and this information is not publicly accessible. The information regarding allowed amounts is an average from an internet search in the 90046 area, coupled with my experience in healthcare and ranges I have seen. Each plan has their own “allowed amount” rate of reimbursement for out of network providers, and this can vary largely between insurance plans.
In my experience, patients are often surprised at how economical out of network providers can be with their current health-insurance plan, and most folks have better outcomes and are happier with their healthcare if they connect with their provider, their provider cares about them, and has expertise in their unique health needs. From both my personal and professional experience in healthcare, the best outcomes / patient experience and the “cheapest care” are provided at different organizations.
Service: New Patient (60 min)
- CPT Code: 99205
- Billed Amount: $250
- Allowed Amount Range: $300–$600+
- Insurance Covers (70%): $210–$420+
- You Pay After Deductible (30%): $75.00
Service: New Patient (30 min)
- CPT Code: 99203
- Billed Amount: $175
- Allowed Amount Range: $150–$300
- Insurance Covers (70%): $105–$210
- You Pay After Deductible (30%): $52.50
Service: Follow-Up (30 min)
- CPT Code: 99214
- Billed Amount: $175
- Allowed Amount Range: $150–$300
- Insurance Covers (70%): $105–$210
- You Pay After Deductible (30%): $52.50
Service: Follow-Up (20 min)
- CPT Code: 99213
- Billed Amount: $125
- Allowed Amount Range: $100–$200
- Insurance Covers (70%): $70–$140
- You Pay After Deductible (30%): $37.50
Service: Psychotherapy Add-On (16–30 min)
- CPT Code: 90833
- Billed Amount: $75
- Allowed Amount Range: $75–$150
- Insurance Covers (70%): $52.50–$105
- You Pay After Deductible (30%): $22.50
Let’s say your insurance has a lower allowed amount for a level of service 99213, which is $100. At the time of your visit, you would be billed for the cost of the service. Afterwards you would be provided with a Superbill to submit to your insurance. Your insurance has an allowed amount for a 99213 of $100, and insurance covers 70% of the allowed amount, so you would be reimbursed from your insurance of $70. In this situation, your cost for that visit would of totaled $55.
One important factor to note is that medical billing for the level of service is based on the medical complexity of the evaluation. Determining medical complexity is quite complicated and involved, and a 20 minute appointment could easily be either a 99213 or a 99214 depending on the overall medical complexity involved. A simple and often accurate explanation is a 99213 is one stable medical issue that requires a prescription (simple medication refill for one condition). A 99214 is often appropriate for two stable medical conditions that require a prescription, or a chronic medical condition that is not adequately controlled (treatment adjustments etc) or exacerbated. Additionally, let’s say other factors of your health contribute to the medical decision making, this can contribute to medical complexity (typically in situations like these it will increase the medical complexity from a 99213 to a 99214. 99215 are rarely billed in medicine except for established patients where the time for all of the care for that day exceeds 40 minutes).
Unfortunately, health insurances keep their fee schedules and allowed amounts private and this information is not publicly accessible. The information regarding allowed amounts is an average from an internet search in the 90046 area, coupled with my experience in healthcare and ranges I have seen. Each plan has their own “allowed amount” rate of reimbursement for out of network providers, and this can vary largely between insurance plans.
In my experience, patients are often surprised at how economical out of network providers can be with their current health-insurance plan, and most folks have better outcomes and are happier with their healthcare if they connect with their provider, their provider cares about them, and has expertise in their unique health needs. From both my personal and professional experience in healthcare, the best outcomes / patient experience and the “cheapest care” are provided at different organizations.
Tips For Using Your Healthcare Coverage
In General
Understand Your Plan: Know your deductible, copay, coinsurance, and out-of-pocket maximum. This helps you anticipate costs.
Consider Value: Healthcare outcomes are incredibly important, you need a provider who is thorough, trustworthy, and are comfortable discussing any matter so you can make the best decisions for your health.
Keep Records: Save your EOBs and medical bills in case you need to dispute a charge.
Use Preventive Services: Take advantage of fully covered preventive services like annual physicals and vaccinations to maintain your health and avoid future medical costs.
Consider Value: Healthcare outcomes are incredibly important, you need a provider who is thorough, trustworthy, and are comfortable discussing any matter so you can make the best decisions for your health.
Keep Records: Save your EOBs and medical bills in case you need to dispute a charge.
Use Preventive Services: Take advantage of fully covered preventive services like annual physicals and vaccinations to maintain your health and avoid future medical costs.
