We are providing the information below to describe common problems or questions patients have experienced with health insurance and billing. These problems have affected patients both with and without health insurance. We strongly encourage you to review all of this information as a preventative measure.
Quick Links:
Coordination of Benefits | Billing Statements & Collections | Newborn Visits | Administrative Fees | Types of Insurance/Payments
| Coordination of Benefits |
You may not be familiar with this term if your family only has one health insurance provider, but it can affect anyone with private health insurance.
At any time during the year, your health insurance company may ask you to complete a form that verifies all health insurance available to you. Failure to complete this form can result in denied claims, even if you are only insured under one plan. Unfortunately there is no universal name or terminology used to identify this form. In some cases it may appear to be a survey, and the accompanying letter may not clearly indicate a response is required.
It is very important to thoroughly read and respond to all correspondence from your health insurance provider.
If a claim is denied because of this issue, our Billing Department will notify you as a courtesy. Please be aware the health insurance companies often place a deadline to respond and provide the form. If that deadline is missed, the amount due will become the patient responsibility for payment.
Insurance companies will only accept Coordination of Benefits information from you, they will not accept it from a health care provider.
If you would like to voluntarily submit Coordination of Benefits information to your health insurance, call the Member Services phone number on your ID card.
| Billing & Collections |
When there is a balance due on a patient account, PHCA mails a statement each month. At a certain point if we have not received payment or arrangements to make a payment, patient accounts can be turned over to a collection agency.
We cannot emphasize enough the importance of opening all correspondence from PHCA.
We often hear from patients that they received mail from us but did not open or read it because they did not think it was a bill. PHCA does not mail any kind of general visit report; therefore if you receive mail from PHCA it is very likely a billing statement.
If you have questions or concerns about a billing statement, please contact the Billing Department quickly. You should not assume payment may still be forthcoming from your insurance company. Billing statements are only sent after we have billed the insurance company and received any reimbursement available.
As always, the most important step you can take is providing accurate health insurance and current contact information when you visit our office.
If we do not have your current address or phone number, we will not be able to inform you of serious problems such as denied claims or past due accounts. You can also submit this updated insurance or updated address information online via our secure forms.
| Newborn Visits |
Another common billing concern experienced by new parents is billing for newborn visits. It is critical for you to add your newborn to your insurance policy within 30 days of birth, and it will be helpful to you to start this process as soon as possible after birth. You will receive billing statements from our office until your newborn is active on your insurance policy. Once active, we will then bill your insurance carrier directly.
If your child is not added to your policy in a timely manner, you will ultimately be responsible for the balance accrued on your account before your child became active on your policy.
Medicaid
If you are active on Medicaid, The Department of Children and Agency for Health Care Administration issues Medicaid ID numbers and gold cards to pregnant mothers before the baby is born. This is done in an effort to expedite the process of adding coverage for a Medicaid-eligible newborn upon the baby's birth, so that health care providers can verify eligibility and bill claims for reimbursement.
We cannot file claims under your individual Medicaid ID number for services rendered to your newborn; therefore, please be sure you have your newborn's Medicaid ID number when you come in for your first visit.
| Administrative Fees Explained |
We have received many inquiries regarding Administrative Fees for certain types of paperwork, which are listed in the Billing Guidelines form signed by parents/guardians each year.
Special request paperwork that must be completed by a physician takes often takes time and research if requested outside a scheduled visit. Due to the time and effort involved, there are fees associated with completing these forms on special request. There is no charge for most well visit/physical forms if they are requested at the time of a scheduled visit.
We encourage parents to plan ahead and bring any potentially necessary paperwork with you to your child's well visit, such as school forms, sports or camp participation forms, etc.
We have many state and/or county forms available in the office, but if your child's school or activity has a unique form it is necessary for you to obtain the form and bring it with you to ensure you get what you need.
| Types of Insurance / Payments |
There are countless insurance plans available in the marketplace today, and many plans have moved away from the standard co-payment structure. As a result, more and more plans are shifting additional costs to patient responsibility, often in exchange for lower premiums or other incentives. At PHCA it is our policy to collect any type of payment due at the time of service, including balances due from previous visits.
Co-Pay
This is a fixed payment due for any primary care office visit. It is typically printed on the front of your insurance card, and our front desk staff will collect this payment from you when you check in for a visit. Co-pays are due at the time of visit and will not be billed later. Most plans waive co-pays for preventative care visits (i.e. well child checkups).
Co-Insurance
This payment structure allows for a fixed percentage of costs to be paid by the insurance plan, and a fixed percentage to be paid by the patient. A common plan is 80% paid by insurance, and 20% paid by patient. We will do our best to estimate costs up front for your visit, but there can be variations due to testing, screenings, and other factors. This may result in a balance due, for which you will receive a billing statement by mail. In rare cases this can result in a credit on your account, which can be applied to a future visit or refunded by mail (if requested).
Deductible
If you are insured on a plan with an annual deductible (often called High Deductible Health Plan, or HDHP), that means you will have a minimum out of pocket expense that must be met before your insurance plan will cover any health care costs. You will be responsible for all costs associated with any visit(s) until that limit is met. Again, we do our best to estimate costs up front for your visit, but there can be variations due to testing, screenings, and other factors. This may result in a balance due, for which you will receive a billing statement by mail. In rare cases this can result in a credit on your account, which can be applied to a future visit or refunded by mail (if requested).
Balance Due
When there is a balance due on your account, you will receive a monthly billing statement, and our front desk staff will also notify you at check in for any visit. As a reminder, it is our policy to collect any payments due, including an outstanding balance, at the time of service.
This information has been provided to help you avoid some of the common problems patients can experience with health insurance and billing. Additional information about Billing Guidelines is available in a form that parents/guardians sign each year.
We know that navigating the health care industry can be complex and challenging, and we are here to help when we can. You can reach our Billing Department Mon-Fri, 8am-5pm at 813-854-2003, Option 4.