Healthcare costs can be confusing. There are many different terms that make it difficult to understand what is covered by your insurer and what you are responsible for paying. Please see the terms below to help you better understand your healthcare responsibility.
The amount you pay for covered healthcare services before your insurance plan starts to pay. With a $2000 deductible, for example, you pay the first $2000 of covered services yourself. After you have met your deductible, you usually only pay for co-payments and co-insurance. Your insurance company pays the rest.
This is a fixed amount ($20 for example) you pay for covered healthcare services after you have paid your deductible. Let’s say the allowed amount by your plan for an office visit is $100 and you have a co- payment of $20. If you have met your deductible, you are responsible for $20. If you have not met your deductible, you are responsible for the full allowed amount of $100.
The percentage of costs you pay (20% for example) of a covered healthcare service after you have met your deductible. If your health insurance plan’s allowed amount for an office visit is $100 and your coinsurance is 20% and you have met your deductible, you are responsible for $20. If you have not met your deductible, you are responsible for the full allowed amount of $100.
The most you are required to pay for covered services in a plan year. After you spend this amount on deductibles, co-payments and coinsurance, your health plan pays 100% of the cost of covered benefits. The out-of-pocket maximum does not include your monthly premiums. It also does not include anything you spend for services that are not a covered benefit.
In addition to the above terms, we wanted to remind you that as of January 1, 2021, some changes were made to the national guidelines for billing medical office visits. One change we wish to describe is how billing for routine checkups works under the new guidelines.
Under the new system, if we manage a medical problem during a checkup, we are required to document and charge for this service in addition to the usual charge for the checkup itself. For example, if your child is found to have an ear infection during his or her routine checkup, there will be a billing charge for the diagnosis and management of the ear infection in addition to the usual charge for the checkup. Or, if your child has asthma and we discuss how your child's asthma is doing and review the use of his or her asthma medications during a checkup, there will be a billing charge for the management of the asthma in addition to the usual charge for the checkup.
While routine checkups generally do not involve co-pays or deductibles, you may be charged a co-pay or deductible when these additional services are addressed during a routine checkup. Whether you are charged a co-pay or deductible is determined by your insurance company, not by our office. Additional questions about this process can be directed to our billing company or our office manager.
If your visit is due to injuries sustained at work or in a motor vehicle accident, your health insurance will likely deny your claim because another company is likely responsible for payment. Please make sure you bring Auto or Worker’s Comp claim information to your visit.
Payments and payment arrangements may be made online via MyChart. If you need a payment plan and are having trouble setting one up, please contact our office and a member of our team will be happy to help you.
At this time, we do not have an in-house biller on staff. Our partners at A-Stat Medical Billing can help you with your billing and insurance questions. They can also take credit card payments over the phone. They can be reached at 401-723-5533. Their number is also listed on your statement and their office hours are the same as ours. In addition, you can send questions through MyChart. Our office manager reviews messages sent via MyChart and left on our billing voicemail (option 5 off on the phone menu) and will usually return your call within 2 business days.
If you have any questions that are not answered above, please reach out to our office
manager by phone 978-443-6005 Ext 116 or email postroadpeds.om@chppoc.org.