​​​​INSURANCE FACTS

Explanation of Benefits: 

This is a statement sent by your health insurance company to you explaining what medical treatment and services were paid for on their behalf.  On the ‘EOB’ summary from your insurance company, you will see several areas: 
Provider charge – This is what we bill to the insurance company.  We set our charges at a reasonable and customary amount and allow a 20% ‘cash’ discount if charges are paid at the time of the visit for self-pay patients.
Provider Responsibility – This is the discounted amount of the fee that we have agreed to when we contracted with your insurance plan.
Amount Allowed or Allowable Amount – These are typically the charges that will be paid by your insurance, however, if you have not yet met your deductible, this will be your responsibility.  You may see this amount listed under a ‘deductible’ column on an EOB.  

​​Know your financial responsibilities:  There are different categories of patient responsibility.
Co-pay –The amount you pay up front before seeing the doctor.  Some Highmark cards now list a Standard Co-pay and an Enhanced Co-pay.  The amount our office collects is the Enhanced co-pay.  Some plans do require a co-pay for Well Child exams.  The first visit with our office for a newborn is a Weight Check and there is a co-pay required for this visit, as it is not considered a Well Child Visit.
Deductible – The amount of money that you must pay out-of-pocket before the insurance will begin paying on claims and this is not the full amount of the charges. It is the amount allowed by your insurance company as negotiated between your doctor and your plan and the limit can be very low or very high.  Once this deductible has been met, the insurance will begin paying your doctor the allowed amount of the charges.
Co-insurance – This is a percentage of the allowed amount, as negotiated between your doctor and your plan.  If you have a 20% co-insurance, you will be responsible for 20% of the allowed charges and your insurance will pay the remaining 80%.  However, this is not the case for out-of-network providers, which could be higher.  Always know your plan and see an in-network provider when possible.

The Law and Subsidized Insurance:  If your child is covered under Gateway, Medical Assistance or other government subsidized plan, we cannot bypass your insurance and allow you to pay out-of-pocket for the visit.  We must, by law, submit these claims to the insurance company even if you do not want to ‘use’ the insurance.  This is the case even if you have a primary commercial insurance.  

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