Some of the reasons health plans may refuse or deny payment of a claim are: The patient, parent or guardian will remain responsible for any services that are not covered or noted as patient responsibility by the health plan. If by mistake, the health plan remits payment to the patient, payment should be forwarded to our office along with all the paperwork sent to you at the time. If insurance has not paid our claim within 60 days, we may expect payment from the patient. The bill will be sent to the health plan on record for direct payment to our office. The patient, parent or guardian accompanying the patient must pay any co-payment and applicable deductible amounts, as directed by insurance, at the time of service unless prior arrangements have been made with our office.
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Patients unable to provide valid insurance information may be required to pay in full at time of service or reschedule their appointment. We must be notified of any changes, prior to rendering services. The patient, parent or guardian accompanying the patient is responsible for providing our office with a valid and current insurance card. We hope this summary will be helpful in understanding your insurance and obligations. However, it is important that our families understand that ultimately the financial responsibility of these services rests between the patient and the health plan. We are pleased to service our families by providing quality medical services and assisting in the billing process. This would mean if the amount shown in the patient responsibility was already paid to the provider, additional payment should not be due to the provider. The amount noted in the patient responsibility does not include payments already made to the provider for the services. It is important that patients review these statements carefully to insure claims are paid according to the patient’s benefits and plan coverage. In addition to any discount, the explanation of benefits will include payment made by the insurance company, any patient amount owed for the services such as co-pays, coinsurance, deductibles and non-covered services. The negotiated fee or “Contract/Network Discount” is provided to the provider and patient, in a statement referred to as the “Explanation of Benefits”, upon processing of the insurance claim. As a participating network provider, the provider has contracted with the managed care health plan or “Network” to provide services at a negotiated fee which is typically less than the provider’s billed charge. Patients are encouraged to seek care from a “Participating” or “In-Network” physician or “Provider” in order to receive the highest level of reimbursement under their health plan.
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