Business Office Tips

The Minnesota Gastroenterology (MNGI) Business Office has developed the following material to provide patients with a resource to better understand the insurance and billing aspect of health care.  If you have questions about this information, our Business Office can be reached at (612) 871-1145, option 5.

Business Office FAQs

My insurance plan told me that you coded my procedure incorrectly and they won't pay. Why won't you change my diagnosis (ICD) code?
Minnesota Gastroenterology strives to be consistent and compliant with the federal coding regulations set forth by the Centers for Medicare and Medicaid Services (CMS). We are not able to change coded charges in order to manipulate payment methodologies set forth by insurance companies.

Why am I receiving more than one statement?
Depending on the services which were provided during your visit, you may receive more than one statement for the same date of service. Some procedures have professional and technical components, which are billed separately. The professional component includes the actual procedure and interpretation of findings, whereas the technical component includes things such as nursing services, the procedure room and the equipment used to perform the procedure.

For example, if you have a procedure such as a colonoscopy, you can expect to receive more than one bill. Statements may be sent by:

  • The MNGI physician who performed the procedure
  • The hospital or MNGI endoscopy/ambulatory surgery center where you had the procedure
  • A pathologist (Hospital Pathology Associates), if a biopsy of a polyp or tissue sample was needed
  • A laboratory (LabCorp or Prometheus), if blood work was done
  • An anesthesiologist (and/or certified registered nurse anesthetist) if an anesthesia provider is involved in your care.

What fees are included in the facility charges?
Minnesota Gastroenterology's facilities are certified by Medicare and follow strict guidelines for facility (or technical) charges. The facility charge on your statement includes administrative and recordkeeping services, housekeeping items and services, nursing services, services of technical personnel, facility use (pre-operative areas, operating/procedure room and recovery room), diagnostic and therapeutic items/supplies, and anesthesia materials and supplies. These items are not individually priced.

How much will my visit or procedure cost?
The cost for your visit or procedure will depend on what service(s) you receive. Click here to request an online price quote.

I'm being told I need a referral for my appointment, but my doctor already suggested I schedule an appointment at Minnesota Gastroenterology. Isn't this the same thing?
A referral, for health insurance purposes, is a written authorization prepared by the primary care provider or clinic and sent to the insurance plan to recommend that the patient see another health care provider (often a specialist). To obtain a referral, please contact your primary doctor or clinic.

If you will be having a procedure in addition to seeing a doctor, you will need two referrals: one to see the doctor and one for the endoscopy center/facility where you will be having the procedure.

Return to Top

Common Health Insurance Terms

Allowed amount - The amount of the charge for the health care provider's service that the insurance company deems payable by the member's plan.

Claim - A statement of services and associated costs provided to a patient by a provider's office, ambulatory surgical center (ASC), hospital or other provider facility. Claims are sent to insurance plans (most often by health care providers) and are then processed to determine what, if any, payment the plan will make.

Co-insurance - A requirement of some insurance plans that a patient must pay a percentage of any remaining medical expenses after the deductible has been satisfied.

Co-payment - A requirement of some insurance plans that a patient must pay a specific dollar amount out-of-pocket for certain services and/or prescription medication at the time those services are received.

CPT (current procedural terminology) codes - Codes developed by the American Medical Association (AMA) to represent and describe medical, surgical and diagnostic services among providers, insurance plans and patients.

Deductible - A fixed dollar amount which must be paid by a patient before the insurance plan will begin to make any payments for services.

Encounter - Any health care visit by a patient to a health care provider where services are received.

EOB (Explanation of Benefits) - A document providing detailed information regarding how an insurance plan has processed a specific claim. The EOB includes how much of the health care costs have been paid to the provider by the insurance plan and what amount, if any, is the patient's responsibility.

ICD-9 codes - Codes developed to classify and communicate diseases and their associated signs and symptoms among providers, insurance plans and patients.

Medically necessary services - Services furnished by a health care provider to diagnose and treat a patient's illness or injury, which, as determined by a particular insurance plan, are:

  • consistent with the symptoms, diagnosis, and treatment of the condition
  • clinically appropriate in accordance with the applicable standard of care
  • not primarily for the convenience of the patient, the patient's family or the health care provider
  • furnished in the least intensive type of medical care setting required by the patient's condition

Network - The group of physicians, hospitals and other medical care providers with which a managed care insurance plan has contracted to provide health care services to its members.

NPP (Non-physician practitioner) - A health care provider, such as a nurse practitioner or a physician assistant, who is licensed to provide medical care under the supervision of a medical doctor.

Out-of-network - Health care providers who are not included in an insurance plan's network of contracted providers.  Services rendered by out-of-network providers usually result in greater out-of-pocket costs to the member (patient) than those provided by a network provider.

Out-of-pocket maximum - Dollar amounts set by insurance plans to limit the amount of money a patient must pay out of his or her own pocket for health care services during an established period of time.

Pre-certification (or prior authorization) - A requirement by some insurance plans that the health care provider must present advanced notification to the plan that a patient will be receiving a course of treatment. Some services may not be covered, if pre-certification is not obtained prior to treatment.

Pre-existing conditions - Health care conditions for which a patient has received health care services during the three months prior to the effective date of coverage for his or her insurance plan.

Referral - For health insurance purposes, a written authorization prepared by a primary care provider (PCP) or clinic that is sent to a patient's insurance plan to recommend that the patient see another health care provider (often a specialist).

Screening services - Services rendered for preventive purposes to determine if there may be a health condition present even if a patient has not experienced symptoms of the condition.

Screening vs. diagnostic colonoscopy - If you are not experiencing any symptoms (including, but not limited to, diarrhea, rectal bleeding or abdominal pain), which lead your doctor to recommend a colonoscopy, then your procedure is likely to be considered a screening procedure. However, if you have at least one symptom or complaint, the procedure can no longer be considered screening due to federal guidelines.

Usual and customary charges - The cost for a specific service commonly utilized by providers within a geographic area.        

Return to Top

Determining Your Healthcare Benefits

Minnesota Gastroenterology (MNGI) recommends that you call your insurance plan(s) prior to each new provider visit or service you receive to determine your specific benefits and coverage. Talking with your insurance plan(s) in advance does not guarantee coverage or payment for services, but will help you understand and prepare for any possible out-of-pocket health care expenses.

The following questions will help guide you through this process. If your insurance plan(s) inform you that you need additional information from MNGI before they can completely answer your questions, please call our Business Office at (612) 871-1145, option 5, and we will be happy to assist you.

For Any Service

Whenever you speak with an insurance representative, be sure to write down the date and time of the call as well as the name of the person with whom you spoke. You will be able to reference this information in the future should you need additional benefit information or need to appeal/dispute claims.

  • Is this provider in network?
  • What network level or tier is this provider a part of?
  • What are the benefits for my upcoming service that are associated with this network level?
  • Do I need a prior authorization for this service and/or facility?
  • Do I need a referral for this service and/or facility?
  • What benefits do I have for facility charges, if they apply?
  • Do I have coverage to see a nurse practitioner or a physician assistant, or am I required to see a physician?

For Screening Colonoscopy

The following questions should be asked in addition to those above if you will be having a colonoscopy.

  • Do I have screening or preventive care benefits?
  • Is there a benefit cap on my screening or preventive care benefits? If so, what is it?
  • Will my colonoscopy be covered under my screening or preventive benefits?
  • My colonoscopy will be performed at an ambulatory surgery center (ASC). Are associated facility charges covered under my screening or preventive benefits? If not, what out-of-pocket expenses might I incur?
  • What benefits do I have for pathology and lab charges? Are these covered under my screening or preventive benefits?
  • What benefits do I have if my colonoscopy is not considered screening?

Return to Top