Health Insurance 101

Understanding your insurance policy is vital to coordinating your child’s health care. Here are a few tips to ensure the correct handling of your insurance claims:

Your new baby is not automatically added to your insurance plan. You must notify your employer and insurance company to add him/her to the policy.

Your insurance policy is a contract between you and the insurance company.

Charges for services provided may vary depending on many factors.

Well visits are billed based on age, but other visits are billed based on a complicated system of time, complexity, number of diagnoses, and medical decision making. Therefore, charges may not be the same for each visit. In addition, you may be billed for services including (but not limited to) in-house laboratory testing, screening tools, vaccines, procedures, and counseling.

Carry your insurance card with you at all times.

It should have your name or the names of your covered dependents, the policy and group numbers, the claims mailing address and phone number, and the co-pay information. We may not be able to see you without verification of insurance benefits, or you may have to pay out-of-pocket for the visit.

Understand your insurance benefits.

Your insurance plan decides which benefits are covered in full, which apply to your annual deductible, and whether or not they will allow the benefit and pay for the service. We do not make this decision. If your policy does not cover the service, you will be responsible for the full amount.

Patient Costs & Financial Responsibilities

There are three different categories of patient responsibility: Co-pay, deductible, and coinsurance. These usually apply per person, with annual limits for each individual as well as the family as a whole.

Copay

The amount that you must pay up front before seeing a provider. This is a set fee based upon the type of provider (PCP or specialist) and the type of visit (preventative or sick visit).

Deductible

The amount of money you must pay out-of-pocket before the insurance will begin paying toward the claims filed by your doctor’s office.

Coinsurance

is the percentage of the allowed amount that you are still responsible for AFTER meeting your deductible.

Many other charges may be applied to your deductible, including (but not limited to) lab testing, prescriptions, procedures and screening tools. Thus you may not even know that you have met your deductible until we verify it for you. Deductibles and co-insurance amounts reset annually.

Questions you need to ask your insurance company before your child’s next check-up:

Many insurance carriers limit what is covered under the “preventative care” umbrella. They may cover your child’s annual check-up without a co-pay and without having to meet your deductible, but not cover the developmental questionnaire or hearing & vision screening.

Viera Pediatrics follows the American Academy of Pediatrics’ Bright Futures Guidelines for preventative care, and we believe strongly that these tools are not optional. It is your responsibility to notify us if you do not want a screening performed. Once performed, you will be responsible for all uncovered charges.

 An “Explanation” of the “Explanation of Benefits”

We urge you to always check the Explanation of Benefits (EOB) that you receive from your insurance company. You will notice several charges, and the first is usually the provider charge. Office charges are set higher than insurance companies will pay, to “capture” the highest allowable insurance payment.

 

Second, you will see provider responsibility – this is the discounted part of the fee that Viera Pediatrics has agreed to accept when contracting with your insurance plan.

Third, you will see amount allowed by benefit. These charges may be paid by your insurance, or may be passed on to you due to a deductible and/or coinsurance. If a charge is “disallowed” the charge will be passed on to the patient directly, the cost and terms of which are confidential between you and your insurance company.

If your insurance company has decided that they will not pay for a particular procedure/service, the payment will be your responsibility. We have had patients ask us “not to do anything not covered by insurance.” We cannot practically do that as there are thousands of different plans within the insurance companies we accept. We cannot ethically do that as it would violate our standards of care.

Here is another resources that explains the ins and outs of health insurance: 

The Confused Parents Guide to Health Insurance