In order to ease the transition from the practice of medicine to the business of medicine, we have enacted certain policies, which we have outlined below. Many of these policies come from an effort to reduce our costs, and therefore yours. FOR QUESTIONS ON ANY OF OUR FINANCIAL POLICIES, PLEASE CALL OUR BILLING DEPARMENT (956) 542-2273.
PAYMENT DUE AT THE TIME OF SERVICE
This is just a fancy way of saying that what you owe for your visit will be collected when you are here for that very visit. We accept VISA, MasterCard, cash, check or money orders.
- WHO BRINGS PAYMENT: Payment is due regardless of who brings the child in for the service. Grandparents, babysitters, aunts, etc., will be expected to bring in payment for your co-pay, co-insurance or deductible. If you are reachable by phone, we can take your credit card information over the phone and send the receipt home with your child’s caregiver. For separated or divorced parents, financial responsibility still belongs to the parent bringing that child in for treatment. We will not bill another parent; it is your responsibility to bring what you will owe when you arrive.
- FINANCIAL RESPONSIBILITY: Payment is determined from benefits we receive from your insurance company. Regardless of what is quoted or misquoted by them, you are ultimately responsible for any deductibles, co-insurance, or co-pays that are not paid by your insurance company. This includes services they do not think are medically necessary, or do not cover, but that our providers deem necessary, appropriate and/or standard of care for pediatrics.
- WELL AND SICK VISITS AT THE SAME TIME: Your insurance company may cover well and sick visits differently, and it is very important you familiarize yourself with the details of your insurance coverage. No one likes being surprised with a bill! While some insurance may pay for well visits 100% (where there is no cost to you), sick benefits may include a co-pay, co-insurance, and/or deductible. If during a well visit your child is sick or has an issue that is not related to the normal growth and development of your child, and he/she needs treatment and/or medical attention for your concerns, your provider may bill the insurance company for both services. Regardless of whether there is a no charge for the well visit, you will be responsible for any charges passed on to you for any treatments and/or care given not covered.
While insurance companies are better about giving us accurate information, the information they neglect to tell us can often times prevent a claim from being paid. Sometimes they are simply waiting for you to call them to give them some information they need. They will deny payment until they hear from you. Some of these “reasons” include that they are (1) waiting on you to contact them because they want to find out if you have another insurance that would be responsible for the charges, instead of them, (2) waiting to hear from you regarding a discrepancy in demographic information, e.g., and incorrect birthday or sex., or (3) waiting on you to name a primary care physician for your child’s care. Please be aware, balances not paid by them in 120 days for not fault of ours, will become your responsibility. So please, open your mail and answer their questions…..we would greatly appreciate it!
We are in network with most major insurance companies, but if we are not, we can bill as an out-of-network provider if your insurance accepts such claims. Ultimate responsibility in finding if we are an in-network provider rests with you, however. Plans change annually and so can their networks or our affiliation with certain networks. If we are out-of-network, you will be responsible for any out-of-network charges, which are usually higher than those your insurance company passes on to you for in-network providers. When you purchase a new insurance plan, please call them to make sure we are in-network before you sign on the dotted line.
While no one likes to discuss paying bills, it is necessary we have a written policy for our patients so that clarification is given. In order to improve our office efficiency, reduce our overhead expenses, and ensure that we can financially sustain ourselves in order to continue providing our patients the services they are accustomed to, the following are our policies regarding outstanding balances.
All outstanding balances not paid within 120 days may be turned over to a collections agency. All costs incurred in collecting a delinquent account will also be added to your charges. Depending on the amount of the balance, our office is willing to work with you to set up a payment plan not to exceed a 3 to 6 month time frame to be paid in full. Payment plans will be granted on a case by case basis. Any payment plan obligation not met, or not attempted to be met, will be immediately turned over to collections. While we find it unethical to prevent you from obtaining your existing records because of a balance, we do expect that any outstanding balances be paid in full.
TRANSFER OF RECORDS AND FEES: We do not charge a fee for faxing records to another office, but there are associated charges when a paper copy is requested. We make every effort to honor any request for personal copies within 15 days, but no more than 30. For faster service, all payment for records must be received in advance by cash, credit card or money order. We reserve the right to hold records until payment by check is cleared and posted. If you are moving, a release of medical records can be signed at our office if you know the new physician’s practice information, it can be taken with you to fill out, sign and send to us when you get there, or one can be signed at your new office and faxed to us from there. For any portion of your child’s record that needs to be faxed to you, to a school, to a non-medical office or elsewhere, there is no charge for this service. Please also read our Notice of Privacy Practices regarding our policy for providing records.
RETURNED CHECKS: All returned checks will be turned over to the District Attorney’s office, unless payment of the face value of the check, including a $25.00 charge, is not paid within 3 days of being notified. Once turned over to the District Attorney’s Office, you will be charged our $25 fee in addition to the face value of the check, another fee from them, and possibly face arrest and criminal prosecution. Any family that has 2nd check returned for insufficient funds will be turned over to the District Attorney’s office, immediately, and will not be allowed to present checks as a valid form of payment. Only credit card, cash, and/or money order will be accepted.
VACCINES AND THE UNINSURED
If your child does not have insurance, the cost of your vaccines will be picked up by the federal government, under the Vaccines for Children (VFC) program. There will be a $14.85 administrative fee for each vaccine (this fee can change annually). This charge is in addition to any charges for the well visit that the provider does. You may also go to the Cameron County Health Department for vaccines. Please call our billing department for more information.
HOW DO YOU KNOW WHAT IS COVERED?
When you have a new plan, it is important to discover what your per visit responsibilities could be. Knowing the financial lingo involved is sometimes half the battle. Here is a short glossary of terms that you should be familiar with, and questions you can ask your insurance company to make sure you know what you will be expected to pay when you come for your visits. Keep in mind that you could call your insurance three times and get three different answers to the type of coverage you have. That is your written contract with them. Don’t forget to read the fine print!
GLOSSARY OF TERMS:
TYPES OF VISITS
- CHECK-UP: This is old term used to describe any type of doctor visit. Most people still use this term to indicate a well-visit, but some use it for both well and sick visits. For that reason, we avoid using this term as much as people. Consider using sick or well visit to be more specific.
- IMMUNIZATIONS/VACCINES: The terms “vaccines” and “immunization” can be used interchangeably. These are life-saving injections that help your child’s immune system fight a particular disease, like pertussis (whooping cough), polio, or meningitis. Many vaccines require boosters, which are additional doses given to continue revving up your child’s immune system so that it doesn’t forget how to fight that deadly disease.
- SICK VISIT: Any visit that is focused on a specific concern or problem. The child doesn’t necessarily have to be “sick” to fall under this category. A rash, twisted ankle, or behavioral concerns would fall under the sick visit category because it focuses on a specific concern.
- WELL VISIT: Any visit that is routine in nature (e.g. regularly scheduled) that concerns the growth and development of your child at various stages of his/her childhood. This usually refers to the part of the visit that the doctor or physician assistant does.
INSURANCE TERMS THAT MEAN YOU HAVE FINANCIAL RESPONSIBILITIES
- CO-PAY: A flat fee you have to pay at every visit. This is a fee that your insurance company requires you to pay.
- CO-INSURANCE: This is a fee you pay based on a percentage of the reimbursement the office will receive for providing your services. If for example, the insurance pays $100, and you have a 30% co-insurance, you will be required to pay $30 at the time of service.
- DEDUCTIBLE: The amount you have to pay before the insurance will pay for anything. A deductible can be $500 or $5000. It is very important to know how much your deductible is and if it has been met. The insurance company allows a certain charge for each service we provide. That charge is called the allowable. You are required to pay the allowable amount for the services you received. We will send a claim to your insurance company so that they know to apply your charges toward your deductible.
- MAXIUM BENEFIT OR CAP: This is a dollar limit on how much your insurance company will pay for a particular type of service. They may only pay, for example, a maxium of $500 for awell visit and immunization. After this $500 has been reached, you would be paying for the service in full, as if you had no insurance. Some insurance companies limit the number of visits, instead of putting a dollar amount on a service. For example, there are typically 6 well visits scheduled before a newborn turns 12 months old. An insurance company may limit it to 5 out of 6 visits.
QUESTIONS TO ASK YOUR INSURANCE
- What are my vaccine benefits? Does a deductible apply? How much? Do I have a co-insurance? How much? Will a co-pay apply if I only need to get vaccines and do not see my doctor? Is there a maximum benefit or cap on my vaccine benefits? What is that limit?
- What are my sick benefits? Is there a deductible? Co-insurance? Co-pay? How much in each case?
- What are my child’s well benefits? Does a deductible, co-insurance or co-pay apply? How much? Is there a maximum benefit or cap on these services? What is the limit? Is there a limit on the number of well visits I can have in a year? If, so what? Do well benefits end at a certain age?
- What is my benefit year? Does it start over on Jan 1st ? Can my (older) child get one well visit per calendar year or benefit year?
- For any of these services, do I have a co-pay and co-insurance? To which services does this apply?
- Is this information all spelled out clearly in my benefit handbook? If not, can I get this in writing? Is this information available online to me?