TriValley Primary Care - Frequently Asked Questions (FAQ's)

About TriValley Managed Care Payment and Refund
Employer Services Medicare Privacy Notice
Insurance Plans New Patients Selecting a Physician

About TriValley

What is TriValley Primary Care?

TriValley Primary Care is a multi-location, medical group practice, organized as a professional corporation under the laws of the Commonwealth of Pennsylvania. It is physician owned and physician managed. This means that the care you receive, in every respect, is in accordance with the policies of its physician-owners.

What is meant by TriValley being multi-location?

TriValley consists of several medical practice offices located throughout the Bux-Mont region of southeastern Pennsylvania. By being dispersed throughout the region, the physicians in these offices can be better attuned to their local communities. Moreover, TriValley physicians strongly feel that medical offices can get too large, with the attendant problems of impersonal care and poor responsiveness to their patients. In addition to the medical practice offices (listed on left-hand tool bar), TriValley has a Corporate Office in which certain common administrative activities are conducted, such as preparing claim forms sent to the third parties (insurance companies and others), and preparing its payroll.

What is meant by "primary care?"

Primary care is the first line of care, that is, the initial access into the health care system for most people. In the case of TriValley, primary care means that several physicians trained in the medical specialties of family practice and internal medicine formed a group medical practice. The internal medicine physicians have chosen to practice that branch of their specialty concerned with predominantly office based (non-hospital) care. In addition, nurse practitioners, who are specially trained, Masters' degree prepared Registered Nurses, also provide care to TriValley patients.

Is TriValley locally owned?

Yes. TriValley is owned by physicians who practice at its offices, and who reside in the communities it serves.

How did TriValley's physicians come together in one organization?

With the advent of managed care, it was clear that the health care "landscape" was changing dramatically. The role of family physicians, in particular, in setting the course of medical treatment for their patients was being threatened by forces largely outside the local community. In light of this, Drs. H. Jeffrey Wilkins and Richard J. Pierotti, through a series of informal meetings, decided to explore means to collectively shape the medical care provided in this region. As a consequence, other physicians were contacted who had similar views. The outgrowth of this process was a decision to form a medical group practice consisting of primary care physicians. Thus, TriValley Primary Care was born. It began operations on June 1, 1995.

Aren't most practices owned by hospitals, insurance companies and publicly traded, investor-owned corporations nowadays?

You may be surprised to learn that the answer is no. One of TriValley's strengths is that it is physician owned. Moreover, it is locally owned and managed. There continues to be some doubt as to the viability of other models of medical care. The practice of medicine in this country has a long history of local, physician control. This isn't likely to change.

What is the Bux-Mont region?

This is a locally designated region of southeastern Pennsylvania comprising the western portion of mid to upper Bucks County and eastern Montgomery County. It is also referred to as Bucks-Mont, Buxmont, etc., and other variants. The boundaries are roughly the northern boundaries of Montgomery and Bucks counties, the near Doylestown suburbs to the east, Lower Gwynedd-Montgomeryville-Horsham to the south, and Schwenksville and the Perkiomen Valley to the west.

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Employer Services

How can I get employee physicals and other job related health assessments done for my employees?

It's quite easy. Simply contact a TriValley physician or speak with his/her office staff and describe what you need. He or she will work with you to meet your needs.

What other services are available?

TriValley has several Certified Medical Examiners (NRCME) to perform Department of Transportation (DOT) physical qualification examinations of commercial motor vehicle drivers and issue medical certificates. In addition, employers may contract for other occupational health and employment related services. Just contact a TriValley physician or speak with his/her office staff and describe what you need. Please note that none of these are “covered benefits” under a typical health insurance policy. Either the employer or the employee must arrange payment for these services. TriValley is quite willing to contract with employers for these services, but will also accept an employer's guarantee of payment in writing. These type services will NOT be submitted as a claim under a patient's health insurance plan as they will be rejected as a non-covered service.

Workers compensation services are available from all TriValley offices. TriValley providers are pleased to provide workers compensation services to their own (established) patients. In addition, the following offices invite community employers to add their providers to their health care provider panels: Lower Salford and Lansdale.

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Insurance Plans

What insurance plans does TriValley accept?

The list of plans that TriValley Primary Care accepts changes quite frequently. The best advice is to discuss insurance coverage when you make your appointment. Some plans which TriValley hasn't contracted with directly, will subscribe to a network (collection of plans) which TriValley has joined. In addition, along with the rest of the health care industry, there are consolidations and divestments. TriValley may no longer subscribe to a plan which it formerly had. (It's confusing for us, too!)

So, what are the current plans?

Click here for a list of the main insurance plans and networks to which TriValley subscribes. You may return by setting a bookmark here or by clicking on the "Back" key (or equivalent) of your Internet browser. See also, Managed Care.

What if you don't accept my insurance?

You are expected to pay for services rendered at the time of your visit. TriValley will give you a receipt, called a "superbill," with diagnoses and procedures marked so that you can file a claim to your insurance company. Please note that with the continuing growth of managed care, your policy may not cover services from a non-enrolled provider.

What if you don't participate with my primary insurance, but you do accept my secondary insurance?

In general, TriValley will prepare and file the claim in order to process your secondary coverage.

What if I don't have insurance?

If you need immediate medical care, you are urged to seek that care regardless of your insured status.

Health insurance is available for purchase on the federally facilitated marketplace, which can be accessed by visiting www.healthcare.gov. Through this website, you can obtain a quote for healthcare coverage and determine whether or not you (and your family) qualify for federal subsidies.

Another resource available is the PAHealthOptions website: http://www.pahealthoptions.com/. This website offers many insights to consumers navigating the health insurance market, and offers additional resources such as links to the CHIP website and Medical Assistance Website.

If you need assistance applying for state subsidized healthcare through Medical Assistance or CHIP, help is available through the Grand View Medical Access Program. You can learn more about the program, and how they might help you, on their website: https://www.gvh.org/patients-visitors/financial/medical-access-program-at-grand-view-hospital/.

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Managed Care

What managed care organizations does TriValley deal with?

TriValley Primary Care participates (has signed contracts to offer medical care) with the following health maintenance organizations (HMO's): Aetna HMO, Keystone Health Plan East, and Keystone Mercy. In addition it has other managed care arrangements with these and other organizations.

What do you mean by "other managed care arrangements"?

In addition to HMO's, TriValley has signed Preferred Provider Organization (PPO) and Point of Service (POS) agreements with several insurers and networks, including Aetna, Independence Blue Cross, Highmark (Blue Shield), and CIGNA, among others. These plans offer the patient greater choice in the selection of their care providers, but typically cost more than HMO's.

Do TriValley physicians advocate patients joining an HMO?

The decision to obtain medical care from an HMO versus another type of payment program is the patient's alone to make. Much of the care provided today is managed to some extent. In making this decision a patient might consider to what extent he or she has confidence in their primary caregiver (physician) to direct their care. If this trust level is high, then the patient has little to fear from the routine aspects of an HMO. However, participating in an HMO is more than the relationship with the primary physician, so all aspects must be investigated.

Can I be seen by any TriValley provider if TriValley participates with my HMO?

In most cases, a patient is enrolled with a particular physician. Therefore, the short answer is no. In general, a patient must select and be seen by a particular physician or that physician's colleagues in that same office. If you desire to be seen by a physician in another office, you must contact the HMO before the appointment. However, each HMO has its own rules for switching providers. Again, please check with your HMO.

What is a co-payment?

This is a set dollar amount, usually in the range of $ 2 to $ 50, that many managed care plans require the member to pay to the care provider at the time of service. TriValley requires that this be paid on the day services are rendered. Cash and checks; and, MasterCard, VISA, Discover (NOVUS), and STAR cards are accepted.

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Medicare

Do TriValley physicians accept Medicare?

Yes, all TriValley physicians are participants with Medicare. TriValley physicians accept Medicare's allowed amount (allowable charges) as the amount due for services rendered.

Medicare pretty well takes care of the bill, right?

Patients are responsible for an annual deductible amount for outpatient services (Part B services), plus 20 % of the allowed charge. If your visit is the first care you receive in a new year, you may be asked to pay towards your deductible. After the deductible is satisfied, you'll only have to pay 20 % of the allowed amount, called co-insurance.

What is the annual deductible?

This is the amount that a beneficiary must pay before Medicare pays anything. For 2015, the annual deductible for Part B (physician) services is $147. (FYI The deductible was $147 in both 2013 and 2014, $140 in 2012, $162 in 2011, $155 in 2010, and $135 in 2009.) This changes annually based on the annual growth in Part B services to beneficiaries. After the deductible is satisfied, you'll only have to pay 20 % of the allowed amount, called co-insurance.

What is co-insurance?

This is a percentage, currently 20 %, of the Medicare allowed amount. It is paid by the Medicare recipient. Medigap insurance is accepted to cover this. If you do not have Medigap insurance, TriValley asks that the co-insurance be paid promptly.

What is the allowed amount?

Medicare determines the amount that may be charged for a service by a participating provider (your physicians or nurse practitioner). This is called the allowed amount. For each service, TriValley bills Medicare for payment. TriValley receives the allowed amount from Medicare less co-insurance and deductible amount. Both the co-insurance and deductible amounts must be paid by the patient to TriValley.

Will you accept my Medigap policy?

Yes. A Medigap policy or plan is a special type of insurance that pays secondary to Medicare. Medigap policies are a special type of Medicare supplement policy. (Not all Medicare supplements are Medigap.) It is sold by insurance companies, usually through brokers or agents. Any Medigap policy will be accepted up to the limits provided in that policy. All Medigap plans pay for all of the Part B (outpatient services) co-insurance, but few Medigap policies pay for the annual deductible. The key consumer advantage of Medigap plans is that you can compare prices from different insurers as the benefits are standardized for the twelve Medigap plans called "A" through "L".

To learn more about Medigap policies, visit “The Official U.S. Government Site for People with Medicare” at www.medicare.gov. Next, on the left-hand toolbar select Plan Choices, then Medigap (Supplemental Insurance). Note: This site changes frequently. TriValley apologizes if the instructions here are not current.

Will you accept other types of Medicare supplement insurance?

TriValley’s rule is that if a Medicare supplement insurance will pay TriValley directly, then TriValley will accept it up to the benefit level it provides. Barring a separate agreement with that insurer, TriValley will not discount its fees lower than the Medicare allowed amount. Most types of Medicare supplement insurance plans are much less expensive than Medigap policies, but they offer fewer benefits.

What about the Medicare Advantage Plans? Does TriValley accept these?

Due to contractual relationships with some insurers, there are a few Medicare Advantage plans that TriValley providers accept. Please see Insurance Plans in this FAQ section for those it accepts.

TriValley would prefer that its Medicare eligible patients enroll in what is now called “the Original Medicare.” See www.medicare.gov/Choices/Overview.asp. It offers free choice as to physician and facility (hospital and nursing homes, etc.). See www.medicare.gov/coverage/home.asp for the program coverage of Original Medicare. Because there are no intervening contractual ties between you and TriValley, TriValley providers have to earn your trust and meet your needs at every visit. And, you are free to make another selection at any time. In addition, Medicare Advantage plans (formerly called “Medicare + Choice” plans) have had a spotty reputation for staying in certain Pennsylvania counties over an extended period. For these and other reasons, you are encouraged to enroll in (or stay in) “Original Medicare.”

What are the "preventive visits", the Wellness Visit and the Welcome to Medicare Preventive Visit?

Newly enrolled Medicare Beneficiaries may receive a Welcome to Medicare preventive visit within the first 12 months with no out of pocket costs (Original Medicare). The Welcome to Medicare preventive visit "helps you and your doctor develop a personalized plan to prevent disease, improve your health, and help you stay well " (quotes are from the Medicare.gov website, 2012). The components of this visit are specified by Medicare and include "a review of your medical history; preventive tests and screenings; and planning for a healthy future." Please note that Medicare does NOT pay for a routine physical examination. The physical examination is a non-covered service, but may be provided for a fee.

Those Beneficiaries in Medicare for more than one year are entitled to a no cost Wellness Visit. The Wellness Visit may be scheduled every 12 months thereafter. The Wellness Visit is neither an exam nor a physical, but rather it is a means "to develop or update a personalized plan to prevent disease based on your current health and risk factors." With Original Medicare there is no cost to the patient for services covered in the Wellness Visit. "If you get additional tests or services during the same visit that aren't covered under these preventive benefits, you may have to pay coinsurance, and the Part B deductible may apply."

Please ask to schedule a Welcome to Medicare preventive visit or a Wellness Visit by calling for an appointment.

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New Patients

As a new patient, what do I need to do to make my first visit most productive to all concerned?

Here are some pointers for your first encounter with a TriValley Office:

  • Please come to your first appointment 15 minutes early to complete registration forms, etc.
  • All adults must bring a photo ID. A driver's license is preferred. A passport is acceptable.
  • Remember to bring your insurance/payment plan card with you. TriValley staff will scan or copy the card for your file.
  • Bring a list of the medications showing the dosages that you take, or just as well, bring the containers with you.
  • Please come prepared to complete a form that details your past medical history. This will ask dates of meaningful medical events, such as operations you've had.
  • Bring the address of your former care provider so that you can request transfer of your records to the TriValley physician.
  • Please be prepared to pay your insurance plan's deductible, co-payment and co-insurance. If you are not covered by insurance or another payment plan, please be prepared to pay for the first visit. Cash and checks, and MasterCard, VISA, Discover (NOVUS), and STAR cards are accepted.

I will be registering my child with a TriValley physician. Is there anything else to be aware of?

All of the above applies. In addition, please bring your child's social security number and immunization record with you, too.

Note: TriValley Primary Care has a Guide for New Patients on the Our Patient Services page. There are links to forms that may need to be completed to make your visit most beneficial. These forms are available for the patient to complete before the visit.

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Payment and Refund Policies

What is TriValley Primary Care's payment policy?

The responsibility for payment of fees, including co-payments, co-insurance, and deductibles, is the direct obligation of the patient, not his or her insurance carrier. To prevent high administrative costs, it is our policy to ask for payment of co-payments, co-insurances, and deductibles at the time of your office visit.

How may I pay?

TriValley accepts cash or checks; and STAR, MasterCard, VISA, and Discover (NOVUS) cards.

What if I can't pay right away?

If you have any questions regarding payment, please do not hesitate to ask us. We will make every effort to work out an arrangement satisfactory to you and our practice.

Who do I call if I have questions about my statement or status of my insurance?

General billing questions, including information on payments made by your insurance, can be directed to our billing office at 215-257-8601.

How are refunds handled?

Refunds due patients or their responsible parties are remitted automatically if a credit balance exceeds $35.00. These are processed mid-month. We will hold lesser amounts on account, unless you specifically ask for payment to made to you. These refunds will be mailed mid-month following receipt of your request.

I need proof of services to do my taxes. What do I do?

You will be provided a receipt for a payment made in a visit. Please keep the receipt. This should be sufficient for tax purposes. Note: a billing statement is not usually sufficient to document payment for tax purposes.

Note: For more information, please review the Insurance, Payments & Refunds tab under the Practice Topics heading on the Our Practice page. This section covers a wide range of financial matters affecting our patients.

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Selecting a Physician

How can I find a TriValley physician near me?

TriValley is pleased to provide an "Office Locator" feature on the Our Practice page of this website.  Click on the Office Locator link, and enter your zip code.  It's that easy!.  You'll get a report of the TriValley offices closest to that zip code. You are free however to seek care from any TriValley provider, regardless of location. We hope this feature is useful to you or your friends.

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Privacy Notice

What is a Privacy Notice?

A Privacy Notice is a brief description of the manner in which your protected health information is safeguarded by TriValley physicians and staff. Providing you with the Privacy Notice is a requirement of the Health Information Portability and Accountability Act of 1996, called HIPAA.

You may download the TVPC Privacy notice in PDF format HERE.

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