East End Pediatrics Insurance and Office Policies

What you may owe

Understanding Health Insurance

Out of pocket expenses means that even though you have insurance there may be other fees you owe even if you are insured. Sometimes it may be hard to understand why you have to pay this money so the following terms will help you understand the reasons you may have out-of-pocket expenses. If you ever need help understanding your bill please call our office and speak to our billing department.

HMO—An HMO plan means that you must select a primary care physician who will be responsible for coordinating your medical care. If you see a physician other than the one listed as your primary your insurance will not pay for the visit.

PPO/EPO/OPEN ACCESS —These plans DO NOT require a primary care physician to be listed and you can see any physician who is in network with your plan.

POS— This does not necessarily require a primary care physician to be selected, but you may be subject to a specialist copay if you choose not to select one.

COPAY –  Some insurance plans require a copay on office visits. Physicians are obligated to collect a copay if your insurance requires one.

COINSURANCE – Some insurance companies do not have a copay, but they have coinsurance instead. For example if you have 80%/20% coinsurance once we bill the insurance company they pay 80% and you will be responsible for 20% (of the contracted insurance rate). Some insurance companies that have copays have coinsurance as well. The claim needs to be processed by the insurance company and they will determine the amount of co-insurance for each specific patient.

DEDUCTIBLE – A deductible is an amount of money that has to be paid by you before an insurance company will pay the bills. Deductibles can range from hundreds of dollars to thousands of dollars per calendar year. Until a deductible is met you will owe money on every visit and the exact amount is determined by your insurance company. (This can be in addition to the copay).

Coordination of Benefits (COB) – Some insurance companies require an update each year which will ask the policy holder of the insurance whether they have any additional coverage. The insurance company typically sends out a letter that needs to be filled out and mailed back. Until the insurance gets the info back from the policy holder all claims will be placed on hold.  That means if you don’t fill it out we do not get paid by your insurance company and then we will ask you to pays us instead.

Pay online via your portal account