Please note: Payment is due at time of service.
I just received a bill–How did you determine that this amount is my responsibility?
In nearly all cases, our office does not have the authority to decide the amount that you owe: Your health insurance company
makes these determinations. If you have commercial insurance, then our office is reimbursed only the amount that your
insurance company allows to be charged for medical services. So, a great reason for making those monthly premium
payments to your health insurance company is to receive this discounted rate for doctor’s visits and procedures!
Occasionally, your health insurance company may refuse to cover/process a particular service–remember, your insurance
company is obligated to reimburse only what they’ve agreed to cover, and, for example, their reckoning of what is part of
a well visit may not reflect nationally recognized standards of care or what may be medically necessary in individual
cases. If your insurance company refuses to cover a service, then and only then will our office determine what you
owe by applying our 15% self-pay discount. Whenever feasible, our office will alert you to the possibility that a
medical service may not be covered, so that you have an opportunity to decline the procedure.
Why am I being charged a copay/deductible/coinsurance? What do these terms really mean?
Health insurance companies share the medical costs that they already discount for you. Once again, charges for copays
and deductible and coinsurance are determined by your insurance company and form an integral part of your agreement
with your insurer. In fact, because your deductible, coinsurance, and copays are a contractual matter between you and
your health insurance company, our office does not have the authority to modify, discount, or refuse to collect these
charges. Interfering with your deductible, copays, or coinsurance would be a violation of our contract with your insurer
and is prohibited by law.
A Deductible is a predetermined and contractually agreed upon amount that you must pay before your insurer will start
paying a percentage of your healthcare costs. (As a rule, health insurance plans with low monthly premiums have higher
deductibles.) If you have a $1,000 deductible, then you must pay 100% of your medical bills until the amount you’ve been
paying equals $1,000. Just keep in mind, even though you are required to pay 100% of your healthcare expenses, the
amount that you owe has already been discounted by your health insurance company.
Coinsurance is the predetermined and contractually agreed upon percentage that your insurer will contribute once
you’ve met your deductible. So, for example, it’s September and, over the course of the calendar year, you’ve paid
$1,000 in charges for your child’s visits to her PCP, to Urgent Care, and to the ER. Because you’ve met your child’s
deductible, your health insurance company is now responsible for sharing your medical costs and must pay 80%
of your child’s future covered healthcare expenses. You will still be responsible, however, for 20% of those charges.
Copays are a predetermined and contractually agreed upon amount that you must pay at the time of service. Your
copays are usually listed on the front of your insurance card. Ultimately, what your insurer determines that you
owe for a medical service will be reduced by the amount of the copay that our office collects on the day of service.
(Again, our office is prohibited from either discounting or refusing to collect your copays.)
The Out-Of-Pocket Maximum is a predetermined and contractually agreed upon LIMIT to what you must pay
over the course of a year and takes into account your copays, deductible, and coinsurance. So, if your Out-Of-Pocket
Maximum is $2,000, your health insurance company is obligated to reimburse 100% of your future covered
healthcare costs, once your insurer determines that the cumulative total of your copays, contributions to
deductible, and 20% coinsurance responsibility have met the $2,000 maximum.
Will I be responsible for copays, deductible, and/or coinsurance when my child is seen for wellness?
In nearly all cases, no! With very few exceptions, health insurance companies must reimburse 100% of the covered
services included in well visits. Three questions to ask your insurer before your child’s wellness visit, however, is
1.) whether there is a limit to the number of well visits that your child is permitted over the course of the calendar
year; 2.) if your child is permitted only 1 wellness visit/physical over the course of the year, whether 365 days must
have elapsed from the date of the previous year’s physical before this year’s wellness visit will be covered 100%;
and 3.) what services are covered and (to be reimbursed 100%) deemed by your insurance company to be medically
necessary at your child’s annual wellness visit. (For example, will a hearing screen be covered?)