Insurance

Please call your insurance prior to every visit so you know your benefits and to make sure Dr. Jones and Dr. Shoptaugh are your child’s assigned physicians.  It is your responsibility to “know” your benefits and coverage.

For all patients on insurance plans in which we are participating providers, your copay and/or deductible amount will be due at the time of service. Our office will gladly file your insurance; however, our relationship is with you and not your carrier. The parent/guardian is financially responsible for all charges incurred in your child’s care and treatment. Payment for any amount not covered after insurance reimbursement is due upon receipt of your first statement.

If we do not accept your insurance or you do not have insurance, we offer a same day cash discount. Please contact our office for details. Payment is expected at the time of service.

We believe divorce, separation and custody agreements should not enter into a child’s medical treatment, as such the individual who is requesting the medical treatment is totally responsible for the payment of the medical bills. We are not a party to your divorce agreement, you are. We will collect co-pays and deductibles from the attending parent.

HELPFUL HINTS

Always bring your insurance card to the office for every visit.

  • Know your benefits and co-pay amount
  • Understand your vaccine and well-child physical benefits
  • Select Dr. Jane (Lyndy) Jones or Dr. Margery (Amy) Shoptaugh as your child’s Primary Care Provider (PCP) and verify prior to every appointment.
  • Know the effective date of the current policy
  • Know if you need a referral to see a specialist or for x-rays

 

Patient Education on Billing Issues 

As you may know, there are very specific regulations about billing for health care services. As your health care provider, we are obligated to follow those regulations in how we report services provided to your child. Additionally, every insurance plan may have different rules.  They vary from insurer to insurer and may even vary between plans of the same insurer. It is your responsibility to know your plan’s benefits.

  • It is not uncommon for patients in the course of a well child check or preventative service visit to receive management and treatment services for a separate and specific problem, such as asthma, headaches, belly aches etc. at the same visit.
  • All physicians must report services using a variety of codes to tell the insurance company what was done and why.
  • Both services must be reported to the insurance company and may result in an additional co-payment or charge as per the insurer’s plan rules, which we are obligated to follow.
  • There are many different insurance companies and plans; addressing a problem may trigger a co-payment or additional charges to your account.
  • Your financial responsibility is determined by the rules of your insurance company, which we are mandated to follow.
  • If you have questions, please check with your insurance plan.

FREQUENTLY ASKED QUESTIONS

Q: Can my child be seen without an insurance card?
A: We require that you bring your child’s insurance card to each visit. If you do not have your card, having the name, dob, SS# and employer of the policy holder may allow us to verify your insurance. If we are unable to verify your insurance, you will be expected to pay at the time services are rendered for the charges incurred.

Q: What is an Insurance Balance?
A: A visit that has been filed with your insurance company and is pending payment.

Q: What is COB?
A: COB stands for Coordination of Benefits. Most insurance companies send out a yearly questionnaire inquiring if you have any other insurance coverage. It is your responsibility that your carrier has the most current information. If a claim is denied due to COB issues- you will be responsible for the bill.

Q: What is EOB?
A: EOB stands for Explanation of Benefits. An EOB provides necessary information about claim payment information and patient responsibility amounts.

Q: Do you bill for “Secondary” insurance coverage?
A: Yes if we are contracted with them.

Q: Why does it take you six months to bill me for something the insurance company did not pay for?
A: We do bill as soon as we can after the insurance company has issued its final determination (EOB). Therefore, it could be nearly six months before we send you an updated statement.

Q: Why am I sometimes charged two copays for a single visit to my doctor?
A: Insurance companies distinguish between diagnosis codes – particularly between what they consider a well code or a sick diagnosis code. A well visit constitutes monitoring of a child’s growth, development and anticipatory guidance. If during your child’s well visit other topics of what an insurance company would consider a sick diagnosis i.e., headache, acne, asthma, chronic illness; are also discussed, the encounter is actually recognized as two “visits” and therefore two copays/charges may be deemed necessary.

The following is a list of insurance companies that we accept.

  • AFMC
  • Aetna
  • Blue Cross Blue Shield
  • Beechstreet
  • Cigna
  • First Health PPO
  • Humana
  • PHCS
  • Tri-Care
  • United Health Care
  • AHCCCS

If your insurance carrier is not listed above or if you have other questions, please call our office and speak with our billing specialist.