Frequently Asked Questions about Billing and Insurance

The facility fee is an indirect cost for a suite of services delivered at a hospital-based clinic or physician office. Facility fee costs include, but are not limited to, using a room or space, having access to state-of-the-art medical equipment and advanced technical resources, and the use of supplies. A hospital-based clinic offers the best healthcare possible.

A hospital-based outpatient clinic is a facility that is owned and operated by a hospital. It can be located on or off the main grounds of the hospital. If you see a doctor at one of these locations, you may see two separate charges in different sections of your bill, one for professional (physician) services and one for a facility fee. Your copayment or deductible may also be affected, depending on your insurance. At UC San Diego Health, hospital-based outpatient clinics include these locations:

• Medical Offices South
• Medical Offices North

• Sulpizio Cardiovascular Center
• Moores Cancer Center
• Koman Family Outpatient Pavilion
• Operating rooms at Shiley Eye Institute

• Cancer services, 1200 Garden View Road
For a complete and current list, please ask a scheduler or front desk representative.

Facility fees are very common in the health care community and have been part of the billing process for decades. The American Hospital Association provides the following justification in support of facility fees to ensure patients have continuous access to medical care:

• Hospitals provide access to critical hospital-based services that are not otherwise available in the community and treat higher-severity patients.
• Hospitals have higher cost structures than physician offices due to the need for access to emergency services.
• Hospitals have more comprehensive licensing, accreditation and regulatory requirements than physician offices.

Facility fees are based on the range of services provided and the complexity of care. In some cases, the facility fees may be equal to or greater than the cost of your other charges. For an estimate of these types of fees prior to receiving services, contact a specialist:

• UC San Diego Health price quote line (toll-free): 844-827-3411
• UC San Diego Health price quote line (local): 858-657-8380
• Email: pricequotes@ucsd.edu

To avoid a facility fee, when you are scheduling your appointment, ask if the type of service(s) could be performed in a physician office instead of a hospital-based clinic. Understand that this may affect available dates, times, and location of the services.

For each visit or hospital stay, your bill may include charges for both hospital/facility services and the services provided by physicians and other providers. As of June 1, 2017, most patients will receive one unified billing statement that includes both hospital and professional services, along with one customer service telephone number for all billing questions.

However, depending on the services provided, you may receive a separate bill from some providers within UC San Diego Health that have their own billing departments. (For a list of these departments, see our main billing page.) Please direct any questions for these departments to the phone number provided on the billing statement.

We ask that payments be made at the time of your visit so you won't be inconvenienced with a statement sent to your home after your visit. Our financial policy is to collect any patient payment responsibility prior to the service being rendered.

There are a few common reasons that this may occur.

• It may take a few days to process the payment and apply it to the charges for your visit. If you believe this is the case, it is best to contact the provider listed at the top of your statement.
• If you paid a copay at the time of appointment, there may be additional copayments after your health insurance plan processes the payments. Make sure to retain the receipt(s) for all payments, and contact the provider on the statement for additional questions.
  
• Your payment may have been applied as a deposit at the time of check-in, and a statement was sent for the remaining balance (after your health insurance plan processed the claim). Again, it is best to contact the provider listed at the top of your statement for a full explanation.

For most insurance health plans, the deductible for the primary health plan must be met before the secondary health plan will pay for services. It is best to contact the provider(s) at the top of your statement(s), or your health plan directly, to inquire if both health plans have been billed and the deductible calculation is accurate.

The hospital refers some ancillary services to outside medical professionals. For example, we may send laboratory tests to outside physicians for additional medical opinions. In addition, x-rays are read by specialty radiologists. These (and other physicians) may bill you directly.

Please call our customer service department, 855-827-3633. 

Your insurance company will send you an Explanation of Benefits (EOB) notice that details the amount it has paid, any non-covered or denied amounts and the remaining balance that you are responsible for paying to UC San Diego Health.

Statements are sent monthly after we receive payment from your insurance company.

If you have a payment plan, any payment will be applied to the payment plan first to keep it in good standing. Payments are next applied to the oldest outstanding balance.

Even if you have authorization for a service, you may still have a financial responsibility. The amount you owe is determined by your health insurance coverage. UC San Diego Health verifies your insurance eligibility and benefits, then determines your financial responsibility, if any. Your policy may require a co-payment, deductible, share of cost, and/or out-of-pocket maximum to be met before coverage is effective.

We will work with you to resolve any billing discrepancies that may occur. If there is an overpayment to your account, it will be transferred to other open self-pay outstanding balances (either for UC San Diego Health and/or UC San Diego Medical Group). The refund of any remaining overpayment will be sent to the patient/guarantor. If the overpayment is due to a payment from a credit card, the first priority will be to send the overpayment back to the credit card issuer; otherwise, a check will be issued to the patient/guarantor. Please allow six to eight weeks for the overpayment to be processed.

If you believe you have made a payment in error or have any other issues or questions related to your payment history with UC San Diego Health, please do not hesitate to call us at 855-827-3633.

If you do not have health insurance, Medicare or Medical, we will send you a bill for any balance not paid at the time services are received. Please pay the bill, or call us to make payment arrangements, as soon as you receive it.

Contact your health plan to enroll your dependents or newborn within the first 30 days of life.

For HMO patients, your insurance company may require an authorization for urgent care, but because of the nature of urgent services, we can often provide authorization after your visit. Contact Managed Care to help with this.

You will receive an Explanation of Benefits (EOB) from your health insurance carrier describing the services they have been charged, the amount they were charged, and the amount that was paid by the insurance carrier. The EOB is not a bill.

UC San Diego Health will make every attempt to ensure that the service(s) we provide has been authorized by your insurance prior to the service(s) being rendered. Not all insurance companies will provide a pre-authorization; therefore, it is UC San Diego Health's expectation that you are familiar with your insurance benefits.

If you are unsure of your medical benefits, call your insurance company to find out if the service(s) you need are a covered benefit. If authorization for service(s) is denied by your insurance carrier, we will inform you. At that point we can provide a quote and make payment arrangements, if necessary.

It is in your best interest to know and understand your plan benefits, as well as any deductible and co-payment amounts that you are responsible for paying. If you do not understand your coverage, we recommend you contact your insurance carrier. They should be able to explain if the service is covered or not. You can also contact a UC San Diego Health financial counselor to review your benefits with you. For more information, see Paying for Care.

Yes, you are financially responsible and will be billed for services not covered by your insurance. If you cannot pay the full balance due, you may call customer service, 855-827-3633, to discuss a payment arrangement. For more information, see Financial Assistance.

Please see see Paying for Care for a full explanation.

UC San Diego Health has contracts in place with many insurance carriers. We strongly encourage you to call insurance carriers directly to verify their participation. For more information, see Insurance Accepted at UC San Diego Health.

Some health care insurance plans have recently shifted financial responsibility to the patient for some common services. The following services are often not covered or only partially paid for by insurance:

• Preventive visits and annual exams, including well woman checkups
• Lab tests associated with preventive visits, annual exams and well woman checkups
• Physical exams for travel, school or work
• Flu or pneumonia vaccines
• Immunizations and travel vaccinations
• Infertility counseling
• Osteopathic manipulations
• Behavioral health and weight management services
• Dermatology services, including wart, mole and skin tag removal
• Birth control
• Botox®
• Acupuncture
• Tuberculosis (TB) screenings
• Screenings for HIV and sexual transmitted diseases (STDs)
• X-rays and electrocardiograms (EKGs)
• Radiofrequency ablations (RFAs)
• MRI and CT scans

Call 800-926-8273.

Insurance companies should notify you directly when a claim is denied. If you have not received an Explanation of Benefits (EOB), you should contact your insurance company directly.

The most common insurance denials received on claims are:
• You were not covered by your insurance plan on the date of service
• Service received was from a doctor/facility outside your plan's network
• The service you received was not covered under your plan
• Your insurance company needs additional information form you

Our Financial Assistance team is dedicated to helping patients with the financial assistance process. Learn more about options on our Financial Assistance page.