INSURANCE 101

The Basics of Health Insurance

Understanding your insurance policy is crucial for effectively managing your child’s healthcare. At Ana HPMD, we are committed to providing you with the guidance and support needed to navigate the complexities of insurance claims. Here are some valuable tips to ensure the smooth handling of your insurance matters:

Contractual Agreements

Your insurance policy represents a binding agreement between you and the insurance company. Similarly, our reimbursement for services is based on a contract between Briarvista Pediatrics and your insurance provider. It is essential to recognize that, just as you are obligated to pay your insurance premium, it is also a contractual obligation for us to bill for services in accordance with our fee schedules.

Varied Charges for Services

Charges for services may vary due to factors such as age, time, complexity, number of diagnoses, and medical decision-making. While check-ups are billed based on age, other visits are subject to a more intricate billing system. This means that charges may differ for each visit, and additional fees may apply for laboratory testing, screening tools, vaccines, procedures, counseling, urgent visits, and after-hours visits.

Always Carry Your Insurance Card

Keep your insurance card with you at all times, as it contains crucial information such as your name, covered dependents, policy and group numbers, claims mailing address, phone number, and co-pay details. Your doctor may require verification of insurance benefits before providing services, or you may be asked to pay out-of-pocket for the visit.

Understanding Insurance Benefits

It’s important to understand the coverage provided by your insurance plan. Your plan determines which benefits are covered in full, which apply to your annual deductible, and whether they approve and pay for specific services. The decision about coverage is made by your insurance company, not your doctor’s office. If a service is not covered by your policy, you will be responsible for the full amount.

In-Network Considerations

Be aware of which specialists and laboratories are in-network with your insurance plan. While you are not restricted from seeing an out-of-network doctor, you may be required to pay the full charges. At Ana HPMD, we are happy to see your child even if we are not in-network with your insurance company. We offer a discount for all out-of-network or self-pay charges when paid at the time of the visit.

At Ana HPMD, we prioritize your child’s well-being, and part of that commitment involves helping you understand and navigate your insurance coverage seamlessly. If you have any questions or need assistance, our team is here to support you in providing the best possible care for your family.

Navigating Patient Responsibility: Your Guide to Co-pay, Deductible, and Coinsurance at Ana HPMD

Understanding your financial responsibility in healthcare is essential for a seamless experience. At Ana HPMD, we want to empower you with information on the three primary categories of patient responsibility: Co-pay, Deductible, and Coinsurance. Familiarizing yourself with these terms will help you make informed decisions about your child’s healthcare.

Co-pay

This is the upfront amount you must pay before seeing a doctor. The fee is predetermined based on the type of provider (general or specialist) and the nature of the visit (preventative or sick visit). Co-pays are usually applied per person, and annual limits exist for both individual and family coverage.

Deductible

The deductible is the out-of-pocket amount you must pay before your insurance starts contributing to claims. The charged amount toward the deductible is the negotiated rate between your doctor and your insurance plan, not the full cost of services. Deductibles apply per person, and there are annual limits for both individual and family coverage.

Coinsurance

This is the percentage of the allowed amount, as negotiated between you and your doctor that you are responsible for after meeting your deductible. It is a shared cost arrangement, and it applies to covered services. Coinsurance amounts also have annual limits for both individual and family coverage.

Additional Charges to Deductible

Several services, including lab testing, prescriptions, procedures, and screening tools, may be applied to your deductible. It’s possible not to realize that you’ve met your deductible until we verify it for you. Both deductibles and coinsurance amounts are reset annually.

Insurance Coverage for Preventative Care

Before your child’s next check-up, it’s crucial to inquire about what falls under the umbrella of “preventative care” with your insurance company. While annual check-ups may be covered without a co-pay or deductible, certain components, such as developmental questionnaires or hearing and vision screenings, may not be covered.

Ana HPMD  Commitment to Preventative Care

We adhere to the American Academy of Pediatrics Bright Futures Guidelines for preventative care. It’s important to note that these tools are not optional. If you choose to decline a screening, please inform us in advance. Once a screening is performed, you will be responsible for any uncovered charges. We offer a discount on non-covered services if paid for at the time of the visit.

At Ana HPMD, we believe that informed patients make the best decisions for their families. If you have any questions about your financial responsibilities or coverage, our team is here to assist you on your healthcare journey.

“I was under the impression that well visits were covered…”

It’s not uncommon for situations to arise during a child’s check-up where an additional issue needs attention on the same day. In such cases, the doctor assigns separate codes for each service. One code corresponds to the preventive medicine service (the well check), while the other pertains to a problem-oriented service (the issue being addressed).

For instance, if you bring your child in for a routine check-up and inquire about a persistent rash, the doctor will conduct the essential well-child examination protocols, encompassing growth assessments, developmental checks, and vaccine administration. Additionally, they will perform a problem-oriented examination of the rash, which may involve prescribing necessary medications.

Similarly, if your child arrives for a scheduled well visit but happens to have a fever and a sore throat that day, the same coding principles apply. This approach is consistent for any abnormality or preexisting problem encountered during the well-child exam.

These dual-purpose visits are always coded as two distinct encounters: a well-child visit and a problem visit. However, with the advent of preventive care coverage without co-pays or deductibles, confusion has arisen among some patients about why they may incur additional costs for a well-child visit. This extra expense often includes a co-pay or payment toward the deductible for the “sick” part of the exam, even when both components occur on the same day. It’s crucial to note that documentation and billing for these two exams must be filed separately to adhere to ethical practices and prevent insurance fraud.

Regrettably, due to your insurer’s payment policy, there are instances where we may need to conduct wellness care and illness care in two separate visits to facilitate appropriate billing. Alternatively, your doctor might determine that addressing a non-urgent concern raised during a good visit is more effectively managed at a separate appointment. While we strive to discuss this at check-in, it remains your responsibility to notify us if you prefer not to incur any additional charges.

Decoding the Explanation of Benefits (EOB): Unveiling the Financial Details of Your Child’s Care

We strongly encourage you to carefully review the Explanation of Benefits (EOB) provided by your insurance company after each visit to Ana HPMD. This document holds essential information about the financial aspects of your child’s healthcare, breaking down various charges and responsibilities. Allow us to demystify the key components of the EOB for your understanding:

Provider Charge

The first entry on your EOB is typically the provider charge. It’s important to note that office charges are intentionally set higher than what insurance companies will pay. This practice aims to capture the highest allowable insurance payment.

Provider Responsibility

The second section outlines the provider’s responsibility, indicating the discounted portion of the fee that Ana HPMD has agreed to accept through the contractual agreement with your insurance plan.

Amount Allowed by Benefit

This section specifies the amount allowed by your insurance benefits. These charges may either be covered by your insurance or passed on to you, depending on factors such as deductibles and coinsurance. If a charge is “disallowed,” it means the cost will be directly passed on to you, and the terms of this transaction are confidential between you and your insurance company.

Payment Responsibility

If your insurance company decides not to cover a particular procedure or service, the responsibility for payment falls on you. While some patients have requested that we avoid procedures not covered by insurance, it’s impractical given the diversity of insurance plans we accept, and it would violate our ethical standards of care.

At Ana HPMD, transparency in financial matters is a priority, and we are here to assist you with any questions or concerns regarding your child’s healthcare billing.

Co-Insurance

Co-insurance refers to the portion of expenses an individual is obligated to pay for healthcare services after fulfilling the deductible. Typically represented as a percentage, for example, the patient pays 20 percent of the charges, and the insurance company covers the remaining 80 percent.

Co-Payment

A co-payment is a predetermined flat fee that individuals pay for healthcare services in addition to what the insurance covers. Unlike co-insurance, co-payments are not specified as a percentage. For instance, some HMOs may require a $10 co-payment for each office visit, irrespective of the services provided.

COBRA

COBRA is federal legislation that enables individuals employed by insured employer groups of 20 or more employees to continue purchasing health insurance for up to 18 months after job loss or termination of employer-sponsored coverage. Additional details can be found on the Department of Labor website.

Denial Of Claim

A denial of claim occurs when an insurance company refuses to honor a request to pay for healthcare services obtained from a healthcare professional, as submitted by an individual or their provider.

Explanation of Benefits

The Explanation of Benefits (EOB) is the insurance company’s written explanation of a claim, detailing the amount paid and the client’s responsibility. Sometimes, it is accompanied by a benefits check.

Health Maintenance Organizations (HMOs)

HMOs are pre-paid or capitated insurance plans where individuals or employers pay a fixed monthly fee for services. Regardless of the types or levels of services provided, the monthly fees remain consistent. Services are typically offered by physicians employed by or under contract with the HMO.

HIPAA

HIPAA, or the Health Insurance Portability and Accountability Act of 1996, is a federal law allowing immediate qualification for comparable health insurance coverage during employment or relationship changes. It also mandates standards for the electronic exchange of healthcare data and outlines measures for security and privacy.

Indemnity Health Plan

Also known as fee-for-service plans, indemnity health insurance involves individuals paying a predetermined percentage of healthcare service costs, with the insurance company covering the remaining portion. Indemnity plans offer the flexibility to choose healthcare professionals.

Preferred Provider Organizations (PPOs)

PPOs offer discounted rates when individuals use doctors from a pre-selected group. Seeking medical care outside the PPO plan may require individuals to pay more for services.

Primary Care Provider (PCP)

A primary care provider, often a physician, is responsible for overseeing an individual’s overall healthcare needs. Acting as a “quarterback,” a PCP refers individuals to specialized physicians for specific care.