Health Insurance Decoded

October 31,2022


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.

Get in touch

If you want to get information about our practice and latest health news, join our newsletter!