Office policies

Financial Policies

Insurance

As a courtesy to our patients, we will gladly file the forms necessary so that you receive the full benefits of your medical coverage. We ask that you read your insurance policy to be fully aware of any limitations of the benefits provided. If your insurance company denies coverage, or we otherwise do not receive payment 60 days from filing your claim, the amount will then become due and payable by you. Remember that your coverage is a contract between you and your insurance company and/or your employer and your insurance company. Although we will make a good faith effort to assist you in obtaining your benefits, we cannot force your insurance company to pay for the services we have provided to you.
 If your family is covered by two insurances (i.e. both parents work and both have insurance), the second insurance often does not pay the portion which the first insurance makes due from you (for example co-pay or co-insurance). Our policy is to collect the lesser of the two insurance’s patient obligations at the time of service. Again, after both insurances have addressed the claims, you may owe a small amount or show a small credit. 

State law governs which insurance is primary and which is secondary, this is not a choice which you can make, nor one which we can make. Please check with both insurances if you are in doubt. You must disclose all insurances that cover your child(ren) at the time of service. Be aware of your insurance coverage. Some insurances do not cover well-child exams and immunizations and  these services can be quite expensive. Feel free to discuss with us payment options and other options for immunizations if your coverage presents a problem.

It is your responsibility to understand your insurance coverage. Please call us as soon as possible if your insurance information changes. If we don’t have current information, claims may be denied and you will be held responsible for payment. Only custodial parents will be entered as responsible parties for minors despite divorce decrees or judgments. We are unable to become involved with these sensitive issues. If your account is past due and is sent to collections, your children may be terminated from the practice. We will make every effort to contact you before resorting to collections; please advise us of new phone numbers or address changes.

Copayments and Deductibles

Depending on your insurance policy, a copayment and/or deductible or coinsurance may be required at the time of service. Payment may be made in cash, by check or by credit card. We also accept Health Savings Account (HSA) cards for payment.Please note that the copayment is a contractual requirement from the insurance company and cannot be written off by the clinic. If you participate in a High Deductible Health Plan (HDHP) and have not yet paid your deductible in full, it is likely that any non-preventive services will require payment at the time those services are rendered. Coinsurance may apply even after meeting your deductible. Please see Health Insurance Decoded for a better explanation of these terms.

Patients Without Insurance Coverage/Non-Covered Expenses

We are happy to work with families that prefer to pay directly for services or do not have insurance. For such patients, a time of service discount will be applied to the bill if settled in full on the day of service. This discount does not apply after the day of the visit. The same discount will be applied to any non-covered charges for patients with insurance, if paid at the time of service. This discount can not be applied toward the “patient responsibility” portion of covered charges, as those charges are already discounted through the contract we maintain with your insurer.

Sick Complaints at a Well Child Check-Up

Please note that your insurance covers preventative care as a bundled service. If you present to a scheduled check-up and your child is sick, or you’d like to address a chronic issue, we are obligated to file a separate visit code with your insurance plan — just as we would if you brought your child in for that complaint on any other day. As such, your regular copay, deductible, and/or coinsurance amounts will apply and payment will be expected at the time of service.

TL;DR

Please understand:

• It is your responsibility to keep us updated with your correct insurance information. If the insurance company you designate is incorrect, you will be responsible for payment of the visit and to submit the charges to the correct plan for reimbursement.
• If we are your primary care physician, make sure our name or phone number appears on your card. If your insurance company has not yet been informed that we are your primary care physician, you may be financially responsible for your current visit.
• It is your responsibility to understand your benefit plan with regard to, for instance, covered services and participating laboratories. For example:
  •  Not all plans cover annual healthy (well) physicals, sports physicals, or hearing and vision screenings. If these are not covered, you will be responsible for payment.
  • For children younger than 2 years, there is a limit as to the number of allowable well visits per year. If the number of visits is exceeded, your insurance company will not pay; you will be responsible for payment.
• It is your responsibility to know if a written referral or authorization is required to see specialists, whether preauthorization is required prior to a procedure, and what services are covered.
• According to your insurance plan, you are responsible for any and all co-payments, deductibles, and coinsurances.
•  Co-payments are due at the time of service.
• Self-pay patients are expected to pay for services in FULL at the time of the visit.
• If we do not participate in your insurance plan, payment in full is expected from you at the time of your visit. We will supply you with an invoice that you can submit to your insurance for reimbursement.
• Patient balances are billed immediately on receipt of your insurance plan’s explanation of benefits. Your remittance is due within 10 business days of your receipt of your bill.
• Any balance outstanding longer than 90 days will be forwarded to a collection agency.
• For scheduled appointments, prior balances must be paid prior to the visit.
• We accept cash, checks, Amex, Visa, and MasterCard credit and debit.
• A $30 fee will be charged for any checks returned for insufficient funds.

Appointment Policies

Appointment Policy

Visits are by appointment only. Patients who walk in without a scheduled appointment will be offered the next available slot.

We value the time we have set aside to see and treat your child. We do not double book well child appointments. If you are not able to keep an appointment, we would appreciate 24-hour notice.

If you are late for your appointment, we do have a 20 minute policy. If you are 20 minutes or more late, we may have to reschedule your appointment.

We strive to minimize any wait time; however, emergencies do occur and will take priority over a scheduled visit. We appreciate your understanding.

Before making an annual physical appointment, check with your insurance company as to whether the visit will be covered as a healthy (well-child) visit.

We require 24 hours’ notice on cancellation/rescheduling of appointments. In the event that you do not show for a well child appointment, there may be a $25 charge to you that is not covered by insurance. 

Telemedicine Visits

Telemedecine Visits

Your child’s next pediatric visit could take place in your home. For your convenience, we are currently offering telemedicine visits whenever possible, even on weekends and holidays.

Scheduling

Please call our office to schedule a telemedicine appointment. All visits must be pre-scheduled, no “walk-in” times available. We guarantee a same-day visit if you call our office by noon. On weekends, the on-call doctor will facilitate telemedicine visits when appropriate.

Privacy Considerations and Consent

Please understand that while this software is HIPPA-compliant, by choosing to do a virtual visit, you are agreeing to electronic communication of you or your child’s health information through audio, video, and/or photo technology. While our software is secure, consider any privacy needs in your space as well.

Preparing for Your Child’s Telemedicine Visit

• Please click the button below to begin your child’s scheduled appointment.
• Your computer/phone’s camera and audio must be enabled.
• Please have your child’s current weight and temperature.
• Have all the medication your child has been taking.
• Write down your main questions.
• Please have your child nearby.
• Be prepared to wait up to 20 minutes for the doctor to arrive at the appointment. If the doctor is running behind, a member of our staff will reach out to let you know.

After-Hours Care

We are very excited to introduce our new after-hours pediatric nurse triage service!

The main goal of this service is to keep you out of the emergency department and ensure that any urgent needs are expertly managed by a triage nurse or one of our providers. If you are calling about an urgent issue, you can call the practice phone number and be connected to one of the nurses from the triage service. This nursing service specializes in pediatrics, and each licensed nurse has over 5 years of ER or telephone triage experience. They follow pediatric protocols when answering your questions about your child. Once connected to a nurse, you may discuss your concerns over the phone or be invited to a video visit. All calls are documented and reviewed by our staff the next business day.

If you are calling after hours about a non-urgent issue and would like one of our doctors to contact you the next day, you will be able to leave a voicemail, and we will make sure to follow up with you in the morning!

We do ask that you are respectful of our time when the office is closed and only call us if it is a true urgent concern.

As always, if your child’s illness or injury is life-threatening, please call 911.

Prescription Refills & Referrals

Prescription Refills

For monthly medication refills, we request 48 hours’ notice during regular business hours. Please plan accordingly.

Referrals

Advance notice is needed for all non-emergent referrals, typically 48 hours.

It is your responsibility to know if a selected specialist participates in your plan.

Remember, we must approve referrals before they are issued.

Accepted Insurance Plans

Please note that it is your responsibility to know what your insurance covers and what your responsible portion is for each service. Please see our insurance information page for more details about potential patient responsibilities.

Many plans are actually owned by larger companies, so even if not listed there is a good chance we ARE in-network with your employer based medical insurance. Please call us if you do not see your plan listed.

Accepted Insurance

United Health Care

Aetna

Blue Cross Blue Shield PPO

Cigna

Oxford 

GHI

HIPP Commercial 

Magnacare 

1099

Health Insurance Decoded

Overview

Peninsula Pediatrics recognizes that health care costs are significant, and insurance premiums have risen rapidly in the last several years. We do our best to provide your children with the best medical care at an affordable cost. There are no hidden fees for any of our other provided services. We have carefully analyzed every charge to minimize your cost while maintaining our excellent level of care.

Please understand that at Peninsula Pediatrics we are committed to practicing evidence based medicine and not letting insurance companies dictate what we can and cannot do. We strive to keep your children healthy through many screening methods, including developmental screening, hearing and vision monitoring, anemia & lead screenings, and vaccinations.

It is impossible for us to keep track of what each individual policy covers, and what we recommend for your child is not based on your insurance company policies/coverage. If you are concerned there may be extra charges at the time of a visit, you should delve deeper into understanding the plan that your family has selected for your children and contact your insurance carrier directly.

Insurance Company Basics: 

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

Our reimbursement for services provided is also based on a contract between Peninsula Pediatrics and your insurance company. We are obligated to report all services provided and to bill for them in accordance with our fee schedules. Just as it would be a contract violation for you to refuse paying your insurance premium, it is also a contract violation to not charge or to undercharge for services we provide.

Charges for services provided may vary depending on many factors.

Check-ups 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) laboratory testing, screening tools, vaccines, procedures, counseling, urgent visits and after-hours visits.

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. Your doctor 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. Your doctor’s office does not make this decision. If your policy does not cover the service, you will be responsible for the full amount.

Understand which specialists and laboratories are in-network with your plan.

The best way to verify that the specialist, doctor, or lab is in-network is by calling your insurance company directly. You are not prohibited from seeing a doctor who is out-of-network, but you may be required to pay the full amount of charges. We are happy to see your child even if we are NOT in-network with your insurance company. We provide a discount for all out-of-network or self-pay charges if paid at the time of the visit.

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.

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

Deductible is 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. The amount charged toward the deductible is the negotiated rate between your doctor and your plan, not the full amount of charges for the services provided.

Co-insurance is the percentage of the allowed amount, as negotiated between you and your doctor, 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.

Peninsula  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. We offer a discount on non-covered services if paid for at the time of the visit.

Charges at a Well Visit?

“I thought well visits were covered…”

Not uncommonly, when a child comes in for a check-up and has another presenting problem that is dealt with on the same day, the doctor codes an additional charge. One charge is considered the preventative medicine service (the well check), and the other is a problem-oriented service (problem visit).

For example, you present for your child’s check-up and ask about a persistent rash he’s had for several weeks. The doctor will perform all necessary well child exam protocols, including growth, development, and administering vaccines, as well as a problem-oriented exam of the rash, including any necessary prescriptions.

Or your child shows up for her scheduled well visit but happens to have a fever and a sore throat that day. The same guidelines would apply for any other abnormality or preexisting problem encountered at the well child exam.

These types of visits are always coded as two separate encounters, well-child and problem visit. When preventative care became covered without co-pays or deductibles, however, many patients began wondering why they had to pay for the well-child visit. The extra cost often includes a co-pay or payment toward the deductible for the “sick” part of the exam, even on the same day of service as the preventative care. The documentation and billing for these two exams must be filed separately, otherwise it would be considered insurance fraud on our part.

Unfortunately, because of your insurer’s payment policy, in some cases we may have to complete your wellness care and your illness care in two separate visits to allow appropriate billing. Your doctor may also decide that a non-urgent complaint brought up at a well visit would be more effectively managed at a separate visit. We will always attempt to address this at the time you check-in for the visit, but it is still your responsibility to notify us if you do not wish to have any extra charges applied.

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 Peninsula Pediatrics has agreed to accept when contracting with your insurance plan.

Third, you will see the 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.

If you are concerned about your coverage, please contact your insurance company prior to your child’s visit to see if the following common physical exam charges are covered:

• Hearing screening (annually from age 3 years)
• Vision screening (annually from age 1 year)
• Hemoglobin (9, and 24 months)
• Lead screening (9 and 24 months)
• Developmental screening (various types of screening tools are used at every well-child visit, beginning with the newborn visit)

If you wish to waive any of the above tests we will require you to sign a waiver acknowledging that you are opting out of a recommended screening test for your child. If your child has had one of the tests elsewhere (i.e. sees an eye doctor yearly, or had blood work elsewhere), the tests do not need to be repeated in our office.

You must notify the front desk of your wish to waive any tests prior to being triaged by our Medical Assistant.

Health Insurance Glossary

Co-Insurance

Co-insurance refers to money that an individual is required to pay for services, after a deductible has been paid. Co-insurance is often specified by a percentage. For example, the patient pays 20 percent toward the charges for a service and the insurance company pays 80 percent.

Co-Payment

Co-payment is a predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers. For example, some HMOs require a $10 co-payment for each office visit, regardless of the type or level of services provided during the visit. Co-payments are not usually specified by percentages.

COBRA

Federal legislation that lets you, if you work for an insured employer group of 20 or more employees, continue to purchase health insurance for up to 18 months if you lose your job or your employer-sponsored coverage is otherwise terminated. For more information, visit the Department of Labor.

Denial Of Claim

Refusal by an insurance company or carrier to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional.

Explanation of Benefits

The insurance company’s written explanation to a claim, showing what they paid and what the client must pay. Sometimes accompanied by a benefits check.

Health Maintenance Organizations (HMOs)

Health Maintenance Organizations represent “pre-paid” or “capitated” insurance plans in which individuals or their employers pay a fixed monthly fee for services, instead of a separate charge for each visit or service. The monthly fees remain the same, regardless of types or levels of services provided. Services are provided by physicians who are employed by, or under contract with, the HMO. HMOs vary in design. Depending on the type of the HMO, services may be provided in a central facility, or in a physician’s own office (as with IPAs.)

HIPAA

A Federal law passed in 1996 that allows persons to qualify immediately for comparable health insurance coverage when they change their employment or relationships. It also creates the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care. Full name is “The Health Insurance Portability and Accountability Act of 1996.”

Indemnity Health Plan

Indemnity health insurance plans are also called “fee-for-service.” These are the types of plans that primarily existed before the rise of HMOs, IPAs, and PPOs. With indemnity plans, the individual pays a pre-determined percentage of the cost of healthcare services, and the insurance company (or self-insured employer) pays the other percentage. For example, an individual might pay 20 percent for services and the insurance company pays 80 percent. The fees for services are defined by the providers and vary from physician to physician. Indemnity health plans offer individuals the freedom to choose their health care professionals.

Preferred Provider Organizations (PPOs)

You receive discounted rates if you use doctors from a pre-selected group. If you use a physician outside the PPO plan, you must pay more for the medical care.

Primary Care Provider (PCP)

A healthcare professional (usually a physician) who is responsible for monitoring an individual’s overall health care needs. Typically, a PCP serves as a “quarterback” for an individual’s medical care, referring the individual to more specialized physicians for specialist care.