Health insurance can be complicated, and many parents have questions about their financial responsibilities after a medical visit. Understanding copays, deductibles, coinsurance, non-covered expenses, and insurance payment processes can help prevent confusion and ensure a smoother experience.
What Do These Insurance Terms Mean?
Copay
A copay is a fixed amount you pay at the time of your visit. For example, if your insurance requires a $20 copay for an office visit, you must pay that amount regardless of the total cost of care.
Deductible
A deductible is the amount you must pay out of pocket before your insurance starts covering costs. If your plan has a $1,000 deductible, you are responsible for paying the first $1,000 of medical services before insurance contributes.
Coinsurance
Even after meeting your deductible, you may still owe a percentage of the bill. This is called coinsurance. For example, if your plan has a 20% coinsurance, you will pay 20% of the total cost, and insurance will cover the rest.
Non-Covered Expenses
Some services may not be covered by your insurance plan, even if they are recommended for your child's health. These include certain age-appropriate screenings, developmental assessments, or diagnostic tests. If a service is not covered, you are responsible for the full cost.
Who Decides What You Owe?
It is important to remember that our practice does not decide what is covered or how much you owe—these decisions are made by your insurance company based on your policy.
Your financial responsibility is based on the contract between you and your insurance company.
If you have questions about coverage, the best way to get answers is by contacting your insurance provider directly. They can explain how much of your deductible has been met, what services are covered, and what your out-of-pocket responsibilities are.
I have met my deductible but your office claim otherwise. Can you not see that my deductible has been met?
A common issue we encounter is when a family believes they have met their deductible, but our system does not reflect it when we verify insurance coverage. This happens for several reasons:
- Your insurance company's records may not be updated in real time. It can take time for payments to process and reflect in the system.
- Other claims may be pending. If another provider has billed for services, but insurance has not yet processed the claim, the deductible may still appear as unmet.
- Insurance updates may be delayed. Insurance companies do not always provide immediate updates on deductible status.
Because we rely on the most recent information available from your insurance company, we must go by what we see at the time of service. If our records show that your deductible has not been met, payment is still required.
What Happens If You Overpay?
We understand that these situations can be frustrating, and we want to reassure you that any excess amount paid will remain as a credit on your account.
- Credit balances can be applied toward future visits.
- If you prefer a refund, we are happy to process it upon request. Simply email at billing@cacpeds.com or visit our office in person to request your refund.
Why Do Charges Vary From Visit to Visit?
Different services fall under different billing categories, which can affect what you owe. Here are some common scenarios:
1. Copay for a Visit, Deductible for Procedures
Your insurance may require a copay for the office visit but classify procedures or testing as part of your deductible.
Example: If your child has an office visit and needs a strep test, you may pay a copay for the visit, but the test itself may go toward your deductible, meaning you must pay for it in full until the deductible is met.
2. Copay and Coinsurance After Meeting the Deductible
Even after you meet your deductible, you may still owe a copay and coinsurance for each visit.
Example: If your deductible is $1,500 and you have met it, you might still owe a $20 copay for an office visit and 10% coinsurance for additional procedures.
3. Deductible for Screenings at Well Visits
Well-child visits are often covered 100%, but some screenings may still apply to your deductible.
These screenings – such as vision checks, hearing tests, screening questionnaires, labs, etc – are critical for your child's health and help detect medical conditions early, may even be medically required, even if they are not fully covered by insurance.
4. When an Office Visit is Coded During a Well Visit
A well visit is designed for preventive care. However, if a separate medical concern is addressed (such as an ear infection or rash), an office visit is also billed in addition to the well visit.
This is not a double charge – it follows strict medical and ethical guidelines. Insurance companies recognize that a well visit and an office visit are different types of care and require providers to bill them separately. This ensures proper documentation and reimbursement for both preventive and problem-focused care.
5. Well Visit Caps
Insurance companies may limit the number of well visits covered in a certain time frame. If your child has already had a well visit within that period, additional preventive visits may not be covered, and you could be responsible for the cost.
When Insurance Claims Get Denied Due to Incorrect Patient Information
Insurance claims can be denied for many reasons, especially when incorrect or incomplete information is provided at the time of service. Common reasons for claim denials include:
- Incorrect Insurance ID or Policy Number – If the insurance card presented has outdated or incorrect information, the claim will be rejected.
- Misspelled Name or Wrong Date of Birth – Even small errors in patient details can result in a claim denial. This is particularly common with twins or siblings who have similar-sounding names. Insurance systems may mistakenly process the claim under the wrong child, leading to incorrect denials. Correcting these errors can be a long process, requiring additional paperwork, identity verification, and multiple rounds of communication with insurance.
- Coverage Lapse or Inactive Policy – If the policy is inactive or coverage has changed, the claim will not be processed.
- Coordination of Benefits (COB) Issues – If a patient has multiple insurance policies, insurance companies require coordination of which plan pays first. If this is not updated, claims can be denied.
- Wrong Provider Network – If a plan requires in-network care and the provider is out-of-network, the claim may be denied or only partially covered.
- Authorization or Referral Missing – Some insurance plans require prior authorization or a referral for certain services, and failing to obtain these can lead to denial.
Because of these potential issues, it is critical to provide accurate and up-to-date insurance information at each visit.
Resubmitting and Getting Paid for Denied Claims is a Looooong Process!
When a claim is denied due to incorrect information, we must correct and resubmit the claim. This process can take weeks or even months due to:
- Additional verification requirements – We must confirm the correct details with the patient and the insurance company.
- Long processing times – Once resubmitted, the claim goes back through the insurance review process, which often takes weeks to months.
- Limited appeal windows – Insurance companies have strict deadlines for appeals, and delays can result in claims being permanently denied.
- Risk of further denials – If any detail remains incorrect, the claim may still be rejected, requiring another round of corrections.
Because of this, we are requiring that patients are pay us if their claim is denied due to incorrect information.
Your Options If a Claim is Denied Due to Patient Error:
- You submit the corrected claim to your insurance for reimbursement.
- We will resubmit the corrected claim on your behalf. Once insurance adjudicates and pays, we will refund your payment that was collected when the denial resulted.
This policy ensures that our practice can continue operating efficiently and serving all patients without delays due to administrative burdens.
What Can You Do?
- Verify your insurance at every visit.
- Provide any necessary referrals or authorizations.
- Notify us of insurance changes immediately.
- Double-check details for twins or siblings with similar names.
- Be patient with claim resubmissions.
- Pay your responsibility in a timely manner.
By ensuring accurate insurance information, you can help prevent claim denials, billing delays, and unnecessary out-of-pocket costs. We try our part to double check information – which is why our staff asks you and reverify information that you may have already provided during your electronic check in. If you have any questions, we are happy to assist, but your insurance provider is the best resource for details about your specific plan.