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.
What we may need to know: In order to ensure that your services are accurately billed and to minimize any out-of-pocket expenses, we will need to know:
The Law and Subsidized Insurance: If your child is covered under Gateway or Medical Assistance, 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.
New ICD-10 Coding Issues:
Beginning October 1st, 2016, If your child arrives for his / her annual wellness exam and has symptoms of an illness or injury, we are now required by ICD-10-CM Guidelines to address ONLY the condition for which symptoms are present and the wellness exam must be rescheduled.
We realize that this is an inconvenience, and we will do our best to expedite your child’s return for the wellness exam. In light of these new coding rules, please contact our office if your child is scheduled for a wellness exam and has symptoms of an illness needing addressed. We appreciate your patience as we all try to navigate the ongoing changes in the industry.
We are currently open to new patients with most private insurances. We are NOT accepting new Self-Pay patients. We only accept patients with insurances that we participate with. Also, Please be advised that the ONLY Medicaid insurance that we currently participate with is Gateway and our panel is full. We are not able to accept any new patients with Gateway or other Medicaid insurance.
*It is VERY important that each renewal period, you check your insurance company's website for any changes. The insurance companies are creating contracts with local hospitals that require their members to use a specific network of physicians. It is impossible for us to keep up with changes in the industry or with newly formed insurance plans since we are not notified about their existence. We also are not kept informed when a particular plan changes its network of physicians.
Below is a list of insurances that we currently do NOT participate with:
*Any MA plan will not be accepted unless it is Gateway for a current patient.