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Patient Bill and EOB’s

We are constantly working with families and insurance plans to re submit, clarify and offer any assistance needed when it comes to understanding their bill.  Please keep in mind that it is your responsibility to know the benefits and limitations that your personal plan includes. However, we hope this post will clarify some aspects and present some tools that you can use to help understand any patient financial responsibility. 

Key concepts we hope you understand as a patient of SuperKids Pediatrics;

1. It is a violation of insurance contract with Physicians and federal and state laws for a Provider to knowingly omit codes or report the wrong code for services performed.  We will NOT engage in this practice. We strongly recommend you find another physician that shares this style before requesting us or suggesting such practice. 
2. After an encounter, SuperKids Pediatrics will subsequently charge or bill any balances (example: deductible / co-insurance) after your insurance has processed your encounter and we have a formal explanation of benefits (EOB) provided by your insurance company that define your financial responsibility.
3. If you believe we have submitted claims with errors to the insurance, we will offer diligent help in verifying, correcting and reprocessing your claim.  If it is concluded that there is no error on our behalf, but you still believe otherwise, it is your responsibility to clarify with your insurance.  Please be aware that patient’s financial adjudication is formalized in your Insurance’s EOB document.  If the EOB claims that you have a patient responsibility, that’s what counts.  Until we receive a new EOB we can’t change any charges due.   
4. If you fail to notify us of a change of insurance, policy id, pay your policy, add a child to a policy before your visit or any change in your insurance coverage, and your claim is denied, charges immediately become patient responsibility and it is your responsibility to fix this situation on a timely matter.
5. We don’t make any charges to credit card on file without; (1) EOB from insurance and (2) an email sent to patient before charges.  We encourage to revisit your OPTIONAL credit card agreement you signed with the practice.  We also ask you to call us to temporary hold a charge so that you can verify any issue with your insurance. 
6. Due to Insurance contract and industry regulations, we can’t change any of our policies or your Insurance outcome. 

Here are some scenarios that can help you understand some charges for a Well Child Visit.  The good news is that due to efforts to be ACA-compliant, many insurances will cover your child’s WCC appointment with no out-of-pocket expense.  Then why are you holding a Bill from your pediatrician?  Glad you ask and, no simple explanation.  The following are common reasons you might receive a bill after a well-child visit:

• While some exchange plans are covering well child visits 100% with no out-of-pocket, other health insurance policies are exempt from the ACA and/or are considered cost sharing and not an insurance.  In these cases, you are subject to your contractual agreement that you sign with your specific policy.  These policies range from no coverage at all for WCC to covering part of the visit but, leaving parts of the encounter as patient responsibility (immunization and screenings for example).  They are mainly called cost-sharing policies, but they also use other names.  Your policy and the EOB from the encounter date of service will determine what services fall under patient responsibility and are billed to patient by provider’s office.

• Received a charge after a Well Visit in which you discuss non-preventive concerns, asked for a specific screening or additional services.  Examples might include, chronic headache, fever, soar throat with other lingering symptoms, testing for asthma or allergies etc.  Insurance does not include in their definition of well child visit a variety of services and does results in additional charges based on the rules of your specific insurance plan.  While the WCC visit is cover, your insurance may include charges for “illness” related evaluation and treatment.  Please understand that this is NOT a new billing policy or an uncommon action from your provider but rather a standard report of a separate event that your insurance is adjudicating patient cost responsibility.  Most of families visiting us appreciate that we provide all needed services at the same time, when adequate, so that they don’t have to come back for a separate visit.  If you decide to discuss additional matters or during a WCC appointment the provider come across a finding that require further services and complication, please be aware that whatever your insurance company decides is not included in the WCC service during the same date of services is your responsibility. 

• You are visiting your practice for an immunization only appointment and your child’s health is “well”.  We encourage you to know as much as you can about your insurance plan and their definition of “Well Child Visit”.  If your child is in good health and visit the office for services like, sport physical, follow up on behavioral conditions, immunization etc, it may NOT be considered a Well Child Visit under your insurance definition and conditions.  Additionally, some services covered during appropriate WCC may not be covered during retuning visits.  For example, appointment made for immunization only in between WCC visits. 

We understand that the healthcare insurance system is convoluted at best and very frustrating at times.  We not only deal with the rules and requirements all day, but we are consumers as well.  I can promise you that we will keep doing our best implementing the best market technology and practices to complete, scrub and post electronically your claims and will offer any help with any clarification or re-submission.

Thanks for your understanding!

Dr. Lizaida Medina Candelaria