Andrea Franchett, MD & Michael Zimmerman, MD
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Temescal Creek Medicine uses a hybrid payment model that has grown out of frustration with an unmanageable, expensive insurance system and a desire to put good, affordable, personalized primary healthcare back in the hands of patients and doctors. The model is designed to minimize the dysfunctional relationship between patients, providers and insurance companies. Over 40% of every $1 spent on primary care traditionally goes toward costs associated with insurance billing and reimbursement. Instead of spending that 40% on back office staff and accounting or giving it to insurance companies, Temescal Creek Medicine uses it to deliver the excellent care that you want and deserve.
Please see below for answers regarding different insurance products:
Insurance and Payment
PPO Insurance Answers
Patients with PPO (Preferred Provider Organization) insurance are responsible for payment at the time of service. We will provide the appropriate claim form for you to submit to your insurance company for reimbursement. For PPO plans we are considered an “out of network” provider. Reimbursement for out of network care varies from plan to plan. Please check with your insurance carrier to verify your reimbursement amount.
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I thought PPO was “the good insurance”? Why are you “out of network”? Currently there are hundreds of different PPO insurance products and they are highly variable. Each insurance plan comes with its own restrictions, copayments, reimbursements and payment rules that change frequently and often without notice. Keeping up with these constant changes takes time and resources. We have made the choice to commit our energy to caring for patients not keeping up with insurance companies.
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Why would I want to go to a provider that I may have to pay more for? Now more than ever PPO insurance carries higher and higher patient copayments and deductibles. This means that patients are often responsible for the first $500 to $1000 no matter where they choose to receive care. Why not assume control over where and how you spend this money? You may use Health Savings Accounts or Flex Spending Accounts to optimize your tax benefits. Different people want and expect different things from their primary care office. If your wants and expectations are currently being met then you may choose to stay where you are. If you find value in our philosophy and approach including longer appointments, less wait time, a deeper relationship with your provider, options for care such as email, video and telephone, and prompt and personalized service then you may find Temescal Creek Medicine makes great sense.
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If I choose to use Temescal Creek Medicine, does that mean I can't use my insurance for my other health care expenses? Absolutely not! While we are out of network, we can help you make in network choices for your services outside of our office including lab, imaging, specialty care and hospitalization. We take our job of helping you make prudent health care spending decisions very seriously and we will not be shy about steering you away from wasteful health care spending. For many patients, the money spent on good primary care will ultimately result in less total out of pocket health care spending.
HMO Insurance Answers
Temescal Creek Medicine contracts with HMO plans through Affinity Medical Group for commercial and medicare advantage plans.
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NOTE: Please call us at 510 230-2372 or email tcmadmin@tcreekmed.com to confirm whether we are currently accepting new HMO patients
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Who do I sign up with? You may sign up with either Michael Zimmerman, MD or Andrea Franchett, MD. As long as one of our providers is on your insurance card you may be seen by either.
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Does my HMO plan cover everything? HMO insurance covers office visits and some procedures. You are responsible for your copayments and any charges not covered under your policy.
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Aren't HMOs bad? What is an HMO anyway? Managed Care or HMO (Health Maintenance Organization) model insurance has received a bad reputation over the years. Some of this is deserved, some is not. The idea behind managed care is to have organized networks of healthcare providers take on real responsibility and accountability for the quality, cost and experience of the care they deliver. The HMO concept is great but unfortunately the first versions of this model were all about managing cost not managing care. The newest iterations of this model are Accountable Care Organizations that do continue to attempt to control costs but do so by focusing on quality and patient satisfaction. The managed care model is distinct from PPO or “fee for service” model in which providers only get paid for doing MORE, with limited if any control on cost or quality. While it is the American Way to want more, we have piles and piles of data demonstrating that more tests and more specialists equals higher costs, more injury, more death and lower quality.
Medicare Answers
Temescal Creek Medicine accepts Medicare insurance. Payment for services not covered by Medicare is due at the time of service. Medicare will usually submit uncovered services to your Medicare Secondary if you have it. Uncovered charges will be billed to your credit card on file.
No Insurance - No Problem!
Temescal Creek Medicine offers transparent, reasonable pricing for visits and services. A little investment in good primary care can avoid much more costly emergency care or hospitalization. We can also help direct patients to the lowest cost medication options. If you have further questions regarding insurance policies, please contact us at tcmadmin@tcreekmed.com.