Billing

Medical offices that take insurance get paid by “coding” what they do. These codes are designated by the Center for Medicaid and Medicare Services (CMS). A new code – G2211 – has been created for primary care providers to indicate that they are following patients longitudinally and are committed to caring for the “whole patient” over time.

Unlike urgent cares and emergency rooms, Center City Pediatrics takes pride in offering this type of care and is excited that CMS is finally recognizing what we do. As such, we will be adding this “code” to all permitted visits, which now includes all patient encounters except for those designated as “Well Visits”.

Unfortunately, many insurance companies are not paying for all the services we provide, even if CMS says we need to document and “code” for it. Some carriers will completely deny payment. Others will pass the charge on to the patient. We are not happy with their position, and feel it is unfair both to us and to you. But, per our contracts with the insurance companies, we must continue to code for services as instructed. If you receive a bill for this code (typically less than $20), we will not be able to waive the charge. Instead, we ask that you follow up with your carrier directly for reimbursement.

We take great pride in providing your child with the highest quality of care possible. Documenting and coding appropriately for the services we provide is necessary for us to continue to serve our families in this way.

We often liken insurance statements to grocery store receipts – each service, procedure, lab and screening is itemized and billed separately. Sometimes, it is difficult to understand which portion is being reimbursed by your carrier and which is your responsibility. Our Billing Department fields a lot of questions about statements, often specific to confusion around well-visit appointments.

It is common for children to be treated for a condition beyond the scope of “routine” visit services, even during their annual, preventative well check. For example, discussion of ADHD, complications from premature birth, ear infections, asthma management or any other complex or acute medical issue do not qualify as “routine care” by insurance carrier definition. As such, insurance companies require us to both document and bill these treatments separately. These fees are in addition to the usual “well visit” fee, and often result in a bill being sent to you.

You can read more in this article from the American Medical Association.

If your child’s insurance plan requires a Primary Care Physician (PCP) to
be chosen, we ask you to ensure you have Center City Pediatrics selected
as their PCP before your first appointment. If we are not chosen as your
child’s PCP, your insurance will deny, and you will receive a bill in the mail
from us. Please contact your insurance and advise them you would like to
make Center City Pediatrics your PCP effective on the date of your child's
first visit at CCP (most of the time, this date is also the child’s date of birth).
There may be a time when the effective date should be a specific date of
service, in which case our billing department will send you an email and
provide you the details. After you call the insurance and resolve this issue,
we ask that you call the CCP billing department and inform us that this has
been completed so that we can have the claims reprocessed from our end
and remove the self-pay balance.

Coordination of Benefits (COB) must be completed by the subscriber of the
insurance. Please contact your insurance company by calling the phone
number on the back of the insurance card and let the representative know
that you would like to coordinate benefits for your child. This just means
that the insurance is questioning whether the child/family have other active
insurance. They would have usually mailed you a letter/postcard in the mail
with 4 or sometimes 5 quick questions. This “questionnaire” may be
necessary for insurance companies to recognize each other. If there is no
COB on file for one of the insurance companies, claims will be rejected and
sent to self-pay until the issue is resolved.

Typically, insurances will cover the number of visits recommended by the
American Academy of Pediatrics (AAP).

• The first week visit (3 to 5 days old)
• 1 month old
• 2 months old
• 4 months old
• 6 months old
• 9 months old
• 12 months old
• 15 months old
• 18 months old
• 2 years old (24 months)
• 2 ½ years old (30 months)
• 3 years old
• 4 years and older- once a year (365 days since last visit).
  Please be aware if a well visit is scheduled too soon, it may not be covered
  by your insurance, and you will receive a bill from our office.

If you are asked to return for a visit by a provider, usually regarding a
weight check due to a feeding difficulty, failure to thrive, low birth weight
etc., the visit will be considered a sick visit {there are 2 types of visits 1)
well 2) sick}. If your “sick visits” are not covered at 100% by your insurance,
you will be responsible for any copay, deductible, or co-insurance due after
the insurance processes the claim. We cannot bill this visit as a “well visit”
because it doesn’t meet the criteria.

If you signed up to have your credit card, debit card or HSA card on file, your card is stored via a secure website where staff cannot access the numbers for security purposes, except the last 4 digits to identify the cards. CCP staff can process payments automatically when there is a card on file if there is an appointment upcoming in the next 7 days. We do not automatically run cards when statements are generated.

If you receive a statement you can pay three ways: 1) by sending in a credit card / check with the statement, 2) by clicking the Make a Payment button on our website or 3) when completing your Phreesia previsit for an upcoming appointment. Only cards on file with active authorizations can be processed automatically by staff.

If you have recently obtained or changed you insurance through your employer but do not have your proof of insurance yet, you may need to call your Human Resources Department to make sure that the paperwork was submitted to the carrier. Sometimes there is a delay in the process.
If paperwork was submitted, you have 3 options:
1. Pay for the child’s visit out of pocket – you will get reimbursed once the insurance pays on the claim after the change becomes active, and as long as the insurance is retroactive to the date of service and/or birth.
2. Reschedule the appointment until your insurance I active and you are in possession of your proof of insurance.
3. Pay for the visit out of pocket but choose to return for vaccines until after the insurance is active.
If paperwork was not submitted:
1. Since the child has no coverage, you will be required to pay out of pocket for the visit in accordance with our self-pay fee schedule but may be eligible to receive federally-funded (VFC) vaccines.
2. The total cost will include the price for the visit plus a $20 administrative fee, regardless of the number of vaccines administered.

Preventative well care visits are crucial for the health and proper development of your child. However, some insurance plans do not cover preventative well care services or they have a benefit cap maximum which limits how much they will pay per year. The federally-funded Vaccine for Children (VFC) program supplies vaccines at a significantly reduced cost for those patients with capped insurance, insurance that doesn’t cover vaccines at all or insurance that only covers certain vaccines. These vaccines are available and can be provided to the patient at the time of their visit.
Please note: Patients with deductibles on immunizations do not qualify for federally-funded vaccines. The state of Pennsylvania provides VFC for those patients who are on Medicaid or who are self-pay. A $20 administrative fee is required prior to the visit.

We are required by Federal law to report the exact services provided and the exact reasons 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 we originally reported something incorrectly to your insurance. You may want to check with your insurance prior to being seen to determine whether a service is covered so you will know what to expect.

If your insurance does not show a claim it could be for one of these reasons:
1. We do not have the correct insurance information on file and claims are going to the wrong payer.
2. The information in our system doesn’t match the information in the payer’s system so claims are being rejected.
3. Claims are being lost.
We send claims electronically, so if a payer doesn’t show a claim on file it is usually due to incorrect or incomplete information. Please contact the Billing Department (215-735-5600 option 3) to verify your information and have us re-submit the claims.

There are different rules insurance companies follow to determine who should be paying as the child’s primary insurance and who should be paying as secondary. Here are a few more popular approaches:
1. In most cases, insurance plans follow the “Birthday Rule” – The policyholder whose birthday falls first in the calendar year will have the primary insurance.
2. If the same person holds two policies, the policy that has been in effect the longest will be the primary insurance.
3. Coordination of Benefits (COB) must be completed by the subscriber of the insurance. This “questionnaire” is necessary for both insurance companies to recognize each other. If there is no COB on file for one of the insurance companies, claims will be rejected and sent to self-pay until the issue is resolved.

Eligibility lists are sent to us every month and change frequently. To be sure that we have your most current coverage information on file, we require a copy of your child’s card at every visit. Eligibility is always checked prior to all services.

It can take up to 2-3 weeks for your insurance to update their records after receiving your Insurance Change Form, adding your newborn to your policy. Since claims are sent automatically, it may be denied because the carrier has not yet updated their records. Once the baby has been added, most insurance companies will do a search for denied claims. Once you have confirmed with your insurance that the newborn has been added to the policy, you can contact our Billing Department (215-735-5600 option 3) for assistance.

It is impossible for your medical provider’s office to know all the details of your insurance plan. Each employer that offers health insurance to its employees has a unique contract with the health insurance company. Thus, there are thousands of subtle differences even within the same insurance carrier. Even your insurance will not guarantee coverage prior to the claim being processed.

If you are unsure about a particular service being covered or have questions regarding your insurance plan, our billing staff would be happy to assist you in contacting your insurance and checking your benefits. Please note that your insurance will make the final coverage determination when they process your claim. Your member benefit manual will give you a good idea of which services are covered under your plan.

Yes. We do accept self-pay patients. There is a discounted fee schedule available to patients who will be paying for services out-of-pocket.

A lot of parents ask this question. Many believe that the billing department makes billing decisions based on a doctor’s notes. This is incorrect! Providers code the visit based on what they do and document it in the record.

Although we have specific prices assigned to each service we provide, we cannot determine what the cost for your visit is until the physician has actually seen your child. There are different levels of office visits, which are determined by the complexity of the condition and the level of medical decision-making involved with the treatment plan. There are also additional charges for immunizations, medications, labs, etc. that are not known until the services are provided.

Visit charges are routinely submitted to the insurance company for payment. The patient is responsible for additional charges, as determined by your insurance company. This includes uncollected co-pays, co-insurance charges, and deductibles. For more details on why you receive a bill after your visit click here.

There is a nationally based system that gives a point value to each service we provide. These points are based on several different aspects of patient care including the location of the service (zip code); place of service (outpatient, office, inpatient), level of knowledge, difficulty, possibility of malpractice, time spent, etc. 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 this information with each other. This is why the same service may cost a different amount at a different doctor’s office.

No, our providers do not currently round at any hospitals. Please be assured, however, that your child will be examined each day by one of the staff physicians while they are in the hospital, per hospital requirements. These physicians will communicate with our office if you identify us as your pediatric practice. Upon the baby’s arrival, please contact our office by phone to register as a patient and to schedule your initial newborn visit.

Yes. For patient convenience, Center City Pediatrics offers an array of services to our patients including lactation consultations, behavioral health counseling, and educational assessments. These services currently do not participate with insurance plans and are paid using a Center City Pediatrics Fee Schedule. Payment for these services is expected at the time of the visit and credit cards are accepted.

Yes. You may bring your child in for a scheduled well visit and they may have an additional medical problem that needs attention that is not routinely covered in a standard preventive medicine visit. For example, if during the well child visit the physician discusses in-depth chronic care diagnoses such as asthma, ADHD, developmental delays, or significant feeding problems, this requires an additional “sick visit” designation. Therefore, your insurance company may require additional co-pay.

There are fundamental differences between a routine well check-up visit and a “sick visit.” This is based on how insurance companies process these claims. Well visits concentrate on preventive issues and cover screening and assessments of your child’s growth and development. Frequently these visits have no associated co-pay.

“Sick visits” are actually all appointments other than well visits as determined by the standard American Academy of Pediatrics of preventive medicine services. All of these visits frequently require a co-pay as determined by your individual insurance plan.