Insurance & Billing

It is often important to learn the formulary drug status when choosing a medication to keep your costs low. 

Our office receives many requests to change a prescription due to insurance cost, but usually we do not know what the preferred medication is. The insurance company provides its members with a formulary, usually available online to its customers but not to the general public (or doctors).

We cannot prescribe the cheapest medicine unless we know what your formulary is. That requires you to look up the medicines on the formulary. You will need to access your insurance company's website private portal to look up this information.

The total amount of covered medical expenses that must be paid by the patient before the insurance company begins paying benefits. After this requirement is reached, the insurer will begin paying according to terms of the contract — often 75-85% of covered medical costs. The patient is responsible for any remaining balance.

The patient pays a share of covered medical costs and the insurance carrier pays an amount based on the policy. For example, when the patient pays $15 of any office visit charge or $3 for any prescription, the insurance carrier is responsible for the balance.

The patient pays a percentage share of covered medical costs and the insurance company pays an amount based on the patient's policy. Examples: 20% of the office visit charge would be $10 of a $50 charge, $12 of a $60 charge, etc. Typically this copayment arrangement includes a deductible and may have other variations.

CDHPs are the fastest growing plan type currently across the county. Employers are shifting financial responsibility to their employees by offering health plans with high deductibles and coinsurance to reduce cost to the business. Most of these plans cover wellness services such as immunizations, well-child visits, and periodic check-ups more than sick services. They usually have a high deductible, but when the deductible is met, the plan pays for services at a percentage (such as 80%) of a defined reasonable and customary fee schedule.

HSAs are tax-favored savings accounts funded with pretax dollars by the individual or the employer. Money can be withdrawn from the account at any time with no penalty or taxes to pay for qualified medical expenses. An HSA can be established only along with high-deductible health insurance plans that meet Internal Revenue Service rules that set the amount of the individual and family deductible. The amount an employee can put in an HSA is capped at the amount of his or her annual deductible of his or her health insurance policy. Any unused funds each year remain in the account, accumulate tax-free and can be used for future medical expenses.

HRAs are funded by the employer and can be used by an employee as pretax dollars. These accounts can be set up independent of any specific health plan or benefit design. Money can be used to pay for medical expenses. HRA funds can also be carried over from year to year. The amount of the contributions to the HRA varies based on the employer. The employer owns the fund and any unused amounts may or may not be transferred on termination of employment, depending on the terms of the fund. Medical spending accounts (MSAs) and flexible spending accounts (FSAs) are versions of HRAs with particular features.

Since we are unable to know the specifics of every insurance plan, we encourage families to understand their own coverage. One would never buy a car without test driving several makes/models and making an informed choice. On the same token, we encourage families to read their insurance information to make an informed decision of which plan to choose (if more than one is offered by the employer). By understanding your insurance coverage, you can help your doctor recommend medical care that is covered in your plan.

• Take the time to read your insurance policy. It's better to know what your insurance company will pay for before you receive a service, get a lab or x-ray, or fill a prescription.
• Some medications, tests or hospitalizations may have to be approved by your insurance company before your doctor can provide them. Our office will charge if the prior authorization takes a significant amount of nursing time, but not if it is a simple form to fax.
• If you still have questions about your coverage, call your insurance company and ask a representative to explain it.
• Remember that your insurance company, not your provider or the physician's office, makes decisions about what will be paid for and what will not.

Children without insurance and those with Medicaid insurance can get vaccines from the Vaccines For Children (VFC) program. Learn more here.

A summary of current activity on an account.

To determine which parent carries primary insurance and which will be secondary if both parents will cover insurance, a birthday rule is generally accepted. Under this rule, the plan of the parent whose birthday occurs first in the calendar year is designated as primary. The date of birth is the determining factor — not the year — so it doesn't matter which spouse is older. Like most rules, the birthday rule has exceptions:

• If both parents share the same birthday, the parent who has been covered by his or her plan longest provides the primary coverage for the children.
• If one spouse is currently employed and has health insurance through a current employer, and the other spouse has coverage through a former employer (e.g., through COBRA), the plan belonging to the currently employed spouse would be primary.
• In the event of divorce or separation, the plan of the parent with custody generally provides primary coverage. If the custodial parent remarries, the new spouse's coverage becomes secondary. And finally, the non-custodial parent's plan would provide a third layer of insurance protection. This order of payment can be altered by a court-issued divorce decree or by agreement, but the insurance companies must be notified.

Information billed to the insurance company for services provided.

The balance due by the policyholder as determined by the insurance company.

Amount the policyholder needs to pay for covered health services before a health plan will begin to pay benefits. Usually a new deductible is met each calendar year.

A detailed explanation from the insurance company that identifies the amount due for services provided. This includes any payments made by the insurance company and any listed co-payment, coinsurance, or deductible due from the policyholder.

The person responsible for paying the bill.

A formal payment plan set up between a patient and our office when payment cannot be made in full.

Designation given to the insurer that your claim will be submitted to first, for payment of services you received. For dependent children, the primary insurance is the parent with the first birthday of the calendar year. For example, if Dad’s birthday is July 1972 and Mom’s is January 1973, Mom’s birthday is first and would be the primary insurance. See also "Birthday Rule".

A formal approval obtained from the insurance company prior to delivery of medical services. Many insurance companies require prior authorization or pre-certification for specific medical services, procedures or medications.

The person who holds and/or is responsible for the medical insurance policy.

Designation given to the insurer that your claim will be submitted to second, for payment of services you received. See also "Birthday Rule."

Virtually every doctor who accepts health insurance uses codes (called CPT codes) that are assigned to every task they and their staff performs. Everything from a simple blood draw, to immunizations, to the ear check, to specimen handling — all these things are “coded” separately.

We use these standard billing codes to tell your insurance company what we have done at a visit. We also submit charges associated with various codes. The insurance company adjusts the portions that they cover and what they expect you to pay as well as what they expect us to write off based on contracts.

Any bill you receive from us is sent after the insurance adjustments have been made and reflect what your insurance company expects you to pay.

The codes we use are to communicate with the the patient’s health insurance company to determine the payment amount that the doctor will receive for his or her services. Each diagnosis, procedure, survey, vaccine, and other service is assigned a code.

The medical office does not choose their own codes. They are standardized among all medical clinics. 

The health insurance company wants to see what was done during a patient’s appointment. Hence, everything the doctor and the staff does has a code. If we fail to code for each issue addressed or every task completed we risk failing to meet metrics set by regulatory boards. This is why we can't simply do a procedure and not bill for it.

For example, if you are coming in for a child’s well visit, the pediatrician will submit a "claim" to the insurance company using the following codes:

• Established Well Visit – 99392
• Developmental Testing – 96110
• Hemoglobin – 85018
• Finger stick – 36416
• Lead Testing – 83655
• Hearing Screen – 92587

If the child gets immunizations, those have codes too:

• Flu – 90660
• MMR - 90707

Vaccine administration also uses a distinct set of codes. To further complicate things, some vaccines have a single administration code used with them, and others have multiple administration codes for a single vaccine.

• Admin – 90460
• Admin – 90461

What happens when something is identified during a well visit that isn't a "well" issue, such as an ear infection? Or what if you ask us to treat the wart or refer to physical therapy for that knee that's been an issue for months?

This question requires the the physician or nurse practitioner to perform an entirely different assessment than the well visit the child was getting.

In order to show the insurance company that a completely different assessment was done, codes are used for those diagnoses and a "sick" visit code is added to the "well visit" code.

Parents often think when they are looking at the bill that the doctor is nickel-and-diming parents, when in reality, it is the insurance company that requires us to show their work in this matter.

The insurance company decides what portion they will pay and what is reasonable but they will have the family pay.

It is the same as going to the restaurant and getting billed for all the side and extra orders. Although the main meal is accompanied by other things, like french fries or a salad, refills, side orders, substitutions and additions to the order are billed as extra. Only it's tricky because no one knows if the insurance company will pay for the sides or if they will require a family to pay for it. 

Why do patients have balances if insurance ought to have paid?

The insurance policy may not pay for all the services performed. So when the billing staff submits a claim for a visit, the health insurance company often comes back and says, "We are not responsible for these codes/services; these are the member's responsibility per the member's health insurance policy.”

For example, the health insurance company may say, the policy your patient chose pays for a vision screen, but not for a hearing screen. Or they may say, we cover the well visit code, but not the ADHD code at the same time as the wellness visit.

We often hear from parents who call to say that they talked to their insurance about a charge and were told that we used the wrong code.

Typically this means that we did a service or ordered labs with a code that is not covered. The insurance complany typically leaves it that we used the wrong code, but rarely offers up which code they will cover.

We can try to change the code to something else that the insurance company might cover, but unless they say which code we should use, it can be a futile game of trial and error.

For example, if we order labs for an obese child to make sure they aren't at increased risk because of high cholesterol, fatty liver, or diabetes, we use a diagnosis code for obesity to explain why the labs are necessary.

If the lab fee is denied by insurance, the parent will get a bill from the laboratory used. (This isn't even Pediatric Partner's bill, since we did not do the lab, but if we pick the right code, maybe insurance will pay for the laboratory fee that is certainly recommended for health risks.) We must change the code so and notify the laboratory so they can resubmit it to the insurance and hope for payment.

We might try any of the following if they apply:

•  E66 for obesity (from experience, this is not paid, so we don't use it)
• Z68.54 BMI, pediatric, greater than or equal to 95th percentile for age (typically what we use on the initial lab order)
• L83 if a patient has Acanthosis nigricans (a skin darkening on skin folds of the neck, often associated with obesity)

If labs were abnormal, we could add the abnormal code, such as "elevated liver enzymes" or "hypercholesterolemia". We can't use these codes initially if it's only a screening because we won't know if we don't test.

Sometimes we resubmit different codes several times before finding the "right" one. (Note, the right one changes from insurance company to insurance company and even year to year within a company.)

One option to avoid getting a bill for extra things covered at well visits is to have you come back later.

If we ONLY do well visit things at the well visit, it is more likely (though not guaranteed) that you will not get a bill. Most of the things recommended in Bright Futures are covered by insurance. 

The "sick" visit issues are never part of a well visit. These might include ear infections, warts, and medication refills for asthma or ADHD. To correctly address and document these, we need to enter it into our charts, which generates codes. Sick visits typically incur a co pay, unlike well visits. So you might have a co pay for the visit added, whether your appointment was scheduled as a sick visit or a well visit, if sick topics are addressed. 

So we can make it convenient and treat that ear infection we see, or refill your child's medications on the day of your well visit. Or we can ask that you reschedule for another day to address the non-well things.

Sometimes the line is very fuzzy. 

Part of a well visit includes depression screens for adolescents. If it identifies depression, it would be poor care to push that to another day. But discussing depression is not a quick add on to a well visit. It deserves time. We deserve to be paid for our time.

By treating additional questions during a wellness visit, the doctor runs the risk of not being paid despite doing the work. On the other hand, not addressing the issues, the doctor runs the risk of upsetting the parent, who will probably think the doc is trying to squeeze another $30 copayment; which is clearly not the case.

One of the major problem with this is that patients don’t understand what they are financially responsible for. Sadly we as medical professionals often don't know either - there are too many companies that are not transparent in their process.

Just like with anything else, you get what you pay for. But patients overlook this issue when purchasing health insurance. They only look at the monthly premiums and chose the lowest one. But by doing that, they are often reducing the amount of coverage, which means patients will get stuck with larger portions of their medical bills.

The health insurance companies, in an effort to keep their premiums low, have shifted the cost to customers and their doctors. While in the past health insurance company’s may have covered 100%, now they are reducing the monthly premiums but only covering 70% of one’s medical expense. Hence all high deductible plans out there.

There are virtually thousands and thousands of different health plans. We even have patients whose parents work for the same company, but have different insurance plan details with the same appearing insurance card.

We don’t have enough manpower or time to sit on the phone verifying every single patient’s healthcare coverage - especially for the additional things added in during a visit. We cannot know that your child will need a breathing treatment when you schedule to be seen for a cough or that your well visit will identify an ear infection in your baby or depression in your teen.

As a practice we believe it is the patient's responsibility to find out what is covered and what is not covered. The more time we spend on the phone with a patient's insurance company, the less time we are able to spend providing health care for our patients. We recognize the futility of this though. We know that you will not get the answers you need from your insurance company - even HR managers struggle to get real answers - and they have connections!

As a practice, we consider that treating patients based on what the insurance covers and what it doesn't, instead of treating by what the patient actually needs, is an unethical way to practice medicine.

Although most doctors will take into consideration health insurance stipulations, they will not compromise a child’s health as a result of health insurance restriction and cheap health insurance coverage plans.

If you have remaining questions, or don’t understand your medical bills, feel free to call our billing office.

The medical industry is different from most because we do not bill our customers directly. We contract with insurance companies, who pay us what they feel is the amount due for certain services. They also have contracts with their policy holders, which describe the payment responsibility for the patient. We cannot alter the contract between a patient and their insurance company. In fact, we do not know what the specifics are between a policy holder and their insurance company. Each contract is different, even with the same insurance company. For example, Blue Cross Blue Shield (BCBS) policies with different companies and with individual plans are different from other BCBS policies, even if they are both PPO or HMOs. There are hundreds of various BCBS policies and each covers different services at various levels. We cannot know what is covered, what is considered not covered at all, or what is considered patient responsibility until we receive payment for services from the company.

We have attempted to discuss our policies on our website so that all patient families can know what our policies are, but we cannot list all covered or non-covered benefits because that is dependent on the contract between you and your insurance company. Please read your policies and ask questions to your insurance company before visiting the doctor so you know your financial responsibility.

We follow strict coding rules and cannot upcode or downcode without breaking the law. This means that a provider should use codes assigned to various sick and well diagnoses and level of difficulty of a visit. Our electronic medical record helps to properly assign codes to visits, which is one reason there is a push by the government to get more physicians on electronic medical records.

One major issue we are seeing is that insurance companies are not all covering separate issues when seen on the same date of service. Pediatric Partners follows the use of CPT as published by the American Medical Association. These CPT codes allow for the use of what is called Modifier -25 to identify separate preventive medicine service (well child exam) and a problem-oriented service (ear infection, hurt foot, earwax removal, etc) on the same date of service.

CPT is very clear on this point. In the guidelines preceding the Preventive Medicine Services codes, CPT states:

“If an abnormality/ies is encountered or a pre-existing problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate office/outpatient code 99201-99215 should also be reported. Modifier -25 should be added to the office/outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided by the same physician on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported."

Some insurance companies argue that if they were to follow these CPT guidelines, physicians would game the system and would more often than not find a medical problem that would enable them to bill for both services, so they simply do not follow the guidelines at times.

We argue that our primary motivation in this situation is to avoid inconveniencing patients who present with acute problems at a preventive care visit. Rather than asking them to return on another date to divide the services, we perform both and submit a claim for both. We realize that this might take a few extra unscheduled minutes of our time, which can affect our office flow, but feel that it overall benefits families because a little longer wait time to avoid coming for multiple visits is preferable to most. Insurance companies handle this situation of addressing multiple issues on the same date differently. If payment for the second service is denied, we write it off, since physicians are usually prohibited under contract from balance billing the patient. If the insurance company says the payment is patient responsibility, it is insurance fraud for us to write off this charge. Many families are upset with us when we do not write things off for them, but we simply cannot by law.

A new twist in the use of the Modifier -25 is that insurance companies are putting this cost to the consumer, which is what leads to many billing questions. The extra cost often includes a second co-pay on the same day of service, since multiple issues were covered on that date. Please understand that it is your insurance contract that requires you to pay this portion, not our office specifically. Again, it would be insurance fraud for us to write off this portion of the charge, so we will not.

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. If you have a health problem you want to discuss with your doctor during your well visit, the doctor may decide to treat that problem and ask you to schedule another appointment for your well visit. If the additional concerns are not urgent, you will be asked to schedule a separate visit to have that problem addressed.

Please understand that we will work with you to the extent that our contracts allow, but we are also a business and in these tough economic times we must be able to cover our increasing costs. Our rent increases yearly, our office staff and nurses salaries increase yearly. Vaccine costs are outpacing reimbursement rates. Malpractice costs are climbing. Costs to buy and maintain our electronic medical record and website to best serve our patients are substantial — a major reason that few physician offices have electronic medical records.

We would like to provide the best care to our patients in a timely and economical manner, but because of many issues, we may have to have you return for separate visits for each separate issue. We hope that this improves patient care, waiting times, and family understanding of billing practices.