Billing & Insurance FAQs


What are co-pays and co-insurance?

Co-pays and co-insurance are out-of-pocket expenses that are part of your contract with your insurance. Co-pays are usually a specific dollar amount (e.g., $20). Co-insurance is usually a percentage of the allowed charges (e.g., 20%). Your insurance card will usually specify what your co-pay/co-insurance portion is. You are obligated to pay your portion prior to insurance paying the rest of the claim.

When are co-pays due?

Co-pays are due at the time of service, prior to seeing the doctor. In the event that your co-pay amount is unknown, we will ask you to pay a specific amount today, then bill you for the difference, or credit your account if you overpaid.

What are deductibles?

A deductible is a clause in your insurance contract that exempts your insurance from paying an initial, specified amount. Once you have met your deductible amount as specified in your contract your insurance will pay claims within your plan provisions.

Why am I getting a bill when I have insurance and/or Medicaid?

Our financial contract is with you, not with your insurance. If there are any unpaid amounts you will be sent a statement to inform you of your account status. There are several reasons why you may be receiving a statement, even with insurance. Some of the most common are:

  • Insurance has denied the claim.
  • Insurance has applied the claim to a deductible.
  • Insurance has not received a copy of your claim, usually due to incomplete/invalid information.
  • Insurance has not responded to the claim within the time frame allowed by Connecticut's Prompt Pay Act.
  • Accurate insurance information has not been provided; an old insurance is being billed.
  • We have received a response from your primary insurance and are in the process of billing your secondary insurance.
  • Insurance has processed the claim and left a higher co-pay amount than what was paid at the time of service.

Why do you need my Medicaid card at every visit? Can't you just look at last month's card?

Medicaid eligibility goes from month-to-month so we require a copy of your child's card to make sure we can accept your benefits as listed. The Medicaid card itself also states, "This card must be presented before receiving Medicaid services." We cannot bill using the previous month's Medicaid card because, although the Medicaid number is usually the same, other critical information may have changed, and those changes may affect your benefits or our ability to accept the card. Presenting a copy of the current month's Medicaid card is also for your protection. If Medicaid denies your claim for eligibility reasons, we need to have a copy of the card for the month in question in order for Medicaid to honor the claim. If we don't receive a copy of your child's current Medicaid card at the time of service, we will set your account up as self-pay until we receive a copy.

Can you bill my ex-spouse for this?

By state statute, both parents are responsible for their minor (under 18) child’s debts. While we will send a statement to whomever is designated on the front side of the registration form, each parent is wholly liable for timely, full payment for care delivered by the practice, as well as any other fees incurred. Divorce proceedings do not alter this basic responsibility. Court judgments that one parent is “responsible” refers to the relationship between the parents; it does not affect the contract with a medical office. Agreement with an insurance company is legally viewed similarly. Thus, waiting for an ex-spouse’s or insurance company’s payment is not an adequate reason for late payment of fees.

How do I add my newborn to my policy?

Most insurance payers give you 30 days to add a baby to your policy. If you miss this deadline you will have to wait until the next open enrollment period to add the child. As soon as your baby is born you will need to get an Insurance Change Form from your Human Resource department. Fill it out completely and return it to HR as soon as possible. Your HR department will then submit the information to the insurance company. Make sure that the information on the form (i.e., spelling of the child's name, birth date, etc.) is correct. If the information we are submitting on claims does not match the information you submitted on the change form, your claims may be denied.

What if my newborn's claims are denied?

It can take up to 2-3 weeks for your insurance to update their records after receiving your Insurance Change Form. In the meantime, we are submitting claims for services rendered so claims are being denied because the insurance can't locate the patient on your policy. Once the baby has been added, most insurance companies will do a search for claims that were denied. Some claims, however, are denied on EDI (front-end) edits and are never accepted into the payer's system. In either case, once you have confirmed with your insurance that the newborn has been added to the policy, you can contact our Billing Office and we will resubmit the claims.

How do I know which of my insurance policies is primary, and which is secondary?

There are different rules that insurance companies follow to determine who should be paying as primary and who should be paying as secondary. Some of these rules are situational, or dependant on other variables. Keep in mind that primary/secondary status may be different for your children than it is for you.

  • Medicaid is always the payer of last resort. This means that Medicaid will always be billed last, regardless of any other coverage or circumstance.
  • Payers go by the “Birthday Rule” to determine primary and secondary coverage in most cases. The policyholder whose birthday falls first in the year will have the primary insurance.
  • If the same person holds two policies, the policy that has been in effect the longest will be the primary insurance.
  • In divorce situations, the divorce decree will determine the order of insurance coverage. Both insurance companies may need a copy of the decree in order to coordinate benefits correctly.

What do I do if both of my insurance policies are paying as primary or denying claims for other coverage?

If both insurance companies are paying claims as if they were the primary payer, there is most likely confusion about who should be primary, or they are unaware that there is another policy. Payers have up to 36 months (3 years) to request or retract overpayments due to coordination of benefit errors. You will want to work with both insurance policies to make sure they have the coordination of benefit information they need to process the claims correctly. Otherwise, you could be stuck with a bill when both payers retract their payments later on. If you are receiving denials on claims, your insurance has most likely requested other coverage information from the policyholder, which they have not received. Most payers will request this information on an annual basis to keep their records as up-to-date as possible. Once the information and supporting documentation (as in the case of a divorce) has been received, they will be able to correctly coordinate benefits.

How do I know when my insurance has responded to a claim?

Your insurance should send you an Explanation of Benefits (EOB) as soon as a claim has been processed. The EOB will show what (if any) was paid on the claim, what (if any) was denied and why, and what (if any) your portion is. Your EOB is usually sent prior to the response being issued to us, so you may see it 1-2 weeks before the payment is posted to your account. Your insurance may also send a request for information (i.e., other insurance coverage) in the form of a letter, and your claims will be pended by the insurance until they get the requested information. Always carefully read anything you receive from your insurance company and respond immediately in order to expedite claim response time.

Why do you charge what you charge for services?

There is a nationally based system (RBRVS) that gives a point value to each service we provide. These points are based on several different aspects of patient care including place of service, level of knowledge, difficulty, possibility of malpractice, time spent, etc. Surgical procedures such as lacerations and fractures also include global packages (follow-up for a specific time after the procedure) in their value. Our charges are based off of this point value system. Although each medical practice uses the same value system to determine their prices, it is against the law for us to share, or “price-fix,” this information with each other. This is why the same service may cost a different amount at a different doctor's office.

How much do you charge for office visits and/or other services?

Although we have specific prices assigned to each service we provide, we can't determine what the cost for your visit is until the physician or nurse practitioner has actually seen your child. There are different levels of office visits, which are determined by the complexity of the condition and/or time spent with the patient. There are also additional charges for immunizations, medications, labs, etc. that are not known until the services are provided. You may contact the Billing Office prior to receiving services for an estimate of charges, but a final determination cannot be made until the physician has seen your child.

Why am I getting a statement when my insurance doesn't even show that you've sent a claim?

If your insurance does not show a claim on file it could be for one of three reasons: we do not have correct insurance information on file and claims are going to the wrong payer, the information in our system does not match the information in the payer's system so claims are being rejected on front-end edits, or claims are being lost. We send electronic claims to most of our payers so if they don't show the claim on file it is usually due to incorrect or incomplete information. Contact our Billing Office to verify the information and have us resubmit the claim.

What if my insurance denies a service as non-covered?

If you find your insurance carrier has denied payment, please first review your plan details with your insurance company. While our staff is sympathetic and wants to assist you, the most they can do is to double-check to see if there were any errors in submitting your claim. However, we have to repeatedly stress, the signed billing agreement we have with all of our patients places the ultimate responsibility for covering any charge an insurance carrier doesn't cover (pays at zero) on the patient/family.

The bottom line is that you need to have read the "fine print" in your policy, and with your coverage in mind, only ask for or accept services you want.

Can you change how you billed my child's visit so my insurance will pay the claim?

We are required by federal law to report the exact services provided and the exact reason for providing them. It is fraudulent to report a different procedure or diagnosis code in order to make a visit “fit” your insurance plan. The only time a service or diagnosis can be changed is if we originally reported them incorrectly to your insurance. You may want to check with your insurance, prior to being seen, to determine whether a service is covered under your plan so you know what to expect.

Can I still be seen if I don't have insurance?

We do accept self-pay patients. Those who pay on the date of service will receive a $20 self pay adjustment. This is a collection savings that we are able to pass on to you because we do not have to spend time or resources collecting for our services after the fact. If payment-in-full is not made at the time of service the collection savings does not apply and you will be responsible for the full amount. We can set up a payment plan with you to help you bring your account current as soon as possible.

What if my insurance doesn't cover preventive care or I have a preventive care maximum benefit?

Preventive care checks are crucial for the health and proper development of your child. However, some insurance plans do not cover preventive care services, or they have a benefit cap which will only pay so much toward preventive care per year. The federal government supplies vaccines at a significantly reduced cost for those patients whose insurance has a benefit cap, does not cover vaccines at all, or does not cover certain vaccines. The State of Connecticut provides Vaccines for Children (VFC) for those patients who have Medicaid, who are self-pay, or who are American Indian or Alaskan Natives. Those who qualify for the VFC program may receive vaccines at this office. The State of CT pays for the vaccine and all that you may be billed is an administration fee.

How do I know if my doctor is on my insurance plan?

Our website lists most of the payers we are contracted with. However, some of these payers are national payers, or have some plans that contract through other entities which we may not be paneled with. In order to determine whether your doctor is covered under your specific plan, please contact your insurance company and give them your doctor's name. They have access to your plan and to the most up-to-date contract information. You will want to verify this information prior to receiving services.

How do I know what services are covered under my insurance plan?

As we cannot (and do not) know everyone's individual policy details, we cannot warn individuals that a particular service is not covered. We can, and do, provide this general guideline. Important: if on reading your policy's "fine print," you are not covered for a particular service, please discuss this with your practitioner. We understand that you might choose to forego it, rather than be responsible for paying for it – but you need to tell us BEFORE accepting the service.

What can I do if I don't agree with how insurance processed my claim?

First, refer to your member benefits manual and make sure you understand your benefits. If, after verification, you determine that insurance processed the claim incorrectly, the next step is to call Member Services at your insurance company. They may be able to resolve the issue over the phone and send the claim back for reprocessing. You can also appeal, in writing, with your insurance company and provide documentation supporting your argument that the claim was processed incorrectly according to your benefits.

Some content courtesy of Utah Valley Pediatrics.

Essex Office One Wildwood Medical Center
35 Saybrook Road
Essex, CT 06426
Tel: 860.767.0168

Hours:
8:30 am to 5:00 pm M-F
8:30 am to noon Saturday


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Old Saybrook Office 30 Elm Street
Old Saybrook, CT 06475
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