About Premier Health Partners of Santa Monica (PHP)

 

What is PHP’s philosophy and mission statement?

• The principal goal of this Practice is to optimize your health and wellness by increasing access to your physician and increasing time per visit with your physician

• At Premier Health Partners of Santa Monica, our goal is to provide the highest quality, comprehensive, and optimal healthcare to our patients.  We want to be their partners in life.

• We will achieve this goal by blending the best of modern, evidence based medicine and advanced technology with the time honored and sacred traditions of our profession:  Respect, Compassion, Empathy, Honesty and Dedication.

• By treating the whole person - emotionally, physically, and intellectually - and encouraging participation, creativity, and innovation among our staff, our organization will have the greatest impact on the health and well-being of our patients, and the world we live in.

 

How does PHP increase time and access to physicians?

• PHP Practice size will be limited to a fraction of the physicians’ previous practice size

• There are only 2 physicians in the PHP Practice which means that in addition to the usual business hours, you will have access after-hours to your own physician on weekdays and every other weekend (varied schedule during vacation/holidays)

 

How does the practice work?

• All new patients are required to participate in the Annual Health Management Plan and pay an annual administrative fee.  See below for details about what this annual fee includes.

• We require every patient to have a comprehensive health care update and exam on a yearly basis to remain part of our practice.

• For non-Medicare patients, half the annual fee is paid at the time of your initial visit or your comprehensive physical.  The remainder can be charged monthly to your credit card, or paid in its entirety at the time of the annual visit.

• For Medicare patients, the annual administrative fee is due in full at the first visit and annually after that.  

• If at any time you feel this model of care is not right for you, you can stop any future payment (or pro-rate if you had paid the annual fee in full) and have your medical records sent to another care provider within 30 days.

• We understand that it may seem more health care than you need now, but since the practice is limited in the number of patients it will serve, it will be a good investment in your future as we expect your medical needs to change over time. 

 

 

Annual Health Management Plan (Non-Medicare)

 

Why is there an annual administrative fee?

• The annual fee pays for your annual comprehensive physical and for your office visits through the year.  It will not cover labs, procedures, and vaccines.

• The doctors provide many services that are not covered by any insurances: emails to/from patients, obtaining prior authorizations for studies/prescriptions, completing outside forms (DMV forms, disability paperwork, life insurance forms, jury duty excuses), etc. 

• The annual fee allows us to restrict the size of the practice in order to provide more personal service and allow each physician to spend more time with the patients.

 

What does the annual administrative fee include?

• The fee covers the cost of your physical and all follow up visits during the year

• Direct email access to their MD

• Urgent appointments accommodated oftentimes same day on weekdays, based on availability 

• Same day prescription refills

• Review of results or records from other providers

• Forms completion (DMV, Jury duty, Disability, etc.)

• Insurance authorizations

 

Can the annual fee be applied towards my insurance deductible?

• For most insurance plans, the annual fees are not applicable towards your deductible.  Some insurance plans may allow you to apply out of network costs to your deductible.  You should investigate and verify this with your insurance carrier. 

 

What insurance plans do you accept?

• Dr. Galier and Dr. Law will be considered out of network for all commercial insurances.  They will be participating providers for Medicare for former established patients (see below for details about Medicare patients)

• Patients can submit bills to their PPO insurance provider for reimbursement (individual patients will need to confirm with their insurers at what rate they will be reimbursed and whether their administrative fee can be applied to their deductible (many insurers do not cover this fee))

 

What does “Out of Network” mean?

• PPO Insurance plans often have different levels of coverage based on what doctors you see or what labs or other services you use. 

• “In network” means the doctor or service has agreed to accept what the insurance company has agreed to pay as full payment.  “Out of network” means the physician, or a place of service (lab/radiology center, etc) has not agreed to this contracted rate, and the patient will pay at the time of service, the fee charged by the doctor or facility.

• Seeing an out of network doctor does not mean that all subsequent services are out of network.  If your lab tests are sent to an in network lab, they should be fully covered.  This holds true for in network radiology, nuclear medicine and various other services.

• HMO insurance typically require that any service be ordered by your HMO contracted provider and any service ordered by a non-HMO provider will not be covered

• Since every insurance plan is different, they will all have different rules regarding this.  You should carefully read about your coverage, or call your carrier.  It is important to ask what percentage you will get back for seeing an out of network doctor.  Some will cover 60-80% of the CONTRACTED rate they give their in network doctors (this is not the same as 60-80% of the doctors charges).  Some will cover nothing out of network.  Remember the contracted rate is very different than the rate you will be charged at the office.

 

What is a Superbill?

• A superbill is a document showing what services you were charged for during your visit.  It is provided to you, along with a claim form for your insurance company.  Since the doctors do not accept what the insurance companies reimburse as payment in full for their services, the patient pays at the time of service. In submitting the bill, you will receive directly any reimbursement they may allow.

• You can usually download and print a claim form off your company’s site.  It might be useful to take print one out and take a look.

 

What happens if I need to go to a hospital?

• Your insurance company has designated hospitals that are “in network” providers.  Typically, Santa Monica UCLA Medical Center and Providence Saint John’s Health Center participate in nearly every PPO plan and Medicare.  In order to keep costs down and office service and availability high, the doctors do not admit patients to the hospital; however, they will follow your day to day progress by speaking to the attending physician in charge on a daily basis.  The doctors will use a small group of board certified internal medicine physicians that are only hospital based (ie, hospitalists) and would be covered by your insurance to provide superior inpatient care if needed. 

 

How does Insurance Coverage work with lab tests? Or xrays? Or seeing specialists?

• Your physician will send your blood work to in-network laboratories (LabCorp, Quest, etc) and will refer you for xrays/radiology services and specialist physicians that are considered in-network for your insurance.

• Although Dr. Galier and Dr. Law may not be in your network, they will keep on file in your record the list of your in-network lab/radiology department.  Two of the most commonly covered/in network labs- Labcorp, and Quest- are located in our new building.  If you are being sent for other studies (radiology, etc), the facility will obtain your pre-authorization for you.  There may be times when the physician might have to spend time with the company to justify the study. 

 

 

Annual Health Management Plan (Medicare)

 

I am a former established patient of Dr Galier or Dr Law and I have Medicare.  Do I pay an annual fee?

• The doctors will accept Medicare, but only for former established patients who are transitioning from their previous practice, and only before their practice fills.  After their practice is full, they will not accept any additional Medicare patients.

• Every patient with Medicare will pay an annual administrative fee.

• This annual administrative fee will cover benefits of the practice that Medicare does not cover.

• The annual fee pays for services that are not covered by Medicare including: emails to/from patients, obtaining prior authorizations for studies/prescriptions, completing outside forms (DMV forms, disability paperwork, life insurance forms, jury duty excuses), etc. 

• This allows us to restrict the size of the practice in order to provide more personal service and allow each physician to spend more time with the patients.

 

What benefits does the Medicare annual administrative fee include?

• The fee covers the cost of increasing your access to your physician

• Direct email access to their MD

• Urgent appointments accommodated oftentimes same day on weekdays, based on availability 

• Same day prescription refills

• Review of results or records from other providers

• Forms completion (DMV, Jury duty, Disability, etc.)

• Insurance authorizations

 

What happens if I need to go to a hospital?

• Your insurance company has designated hospitals that are “in network” providers.  Typically, Santa Monica UCLA Medical Center and Providence Saint John’s Health Center participate in nearly every PPO plan and Medicare.  In order to keep costs down and office service and availability high, the doctors do not admit patients to the hospital; however, they will follow your day to day progress by speaking to the attending physician in charge on a daily basis.  The doctors will use a small group of board certified internal medicine physicians that are only hospital based (ie, hospitalists) and would be covered by your insurance to provide superior inpatient care if needed. 

 

How does Insurance Coverage work with lab tests? Or xrays? Or seeing specialists?

• Your physician will send your blood work to in-network laboratories (LabCorp, Quest, etc) and will refer you for xrays/radiology services and specialist physicians that are considered in-network for your insurance.

• Although Dr. Galier and Dr. Law may not be in your network, they will keep on file in your record the list of your in-network lab/radiology department.  Two of the most commonly covered/in network labs- Labcorp, and Quest- are located in our new building.  If you are being sent for other studies (radiology, etc), the facility will obtain your pre-authorization for you.  There may be times when the physician might have to spend time with the company to justify the study.