Insurance & Billing 101

Deductibles, Co-pays, Co-Insurance, EOBs, DX codes …. It can get confusing! Here’s some helpful information; (These are general guidelines only).

ICD10 / DX (Diagnostic) Code

Coding system that insurance companies use to describe the nature and reason for the visit and/or tests.

CPT Code

Coding system that insurance companies use to describe actual services rendered.

EOB

Explanation of Benefits sent by your insurance company to you, and the practice, outlining how a particular date of service was processed.

Coding for Your Insurance

At Northern Virginia Pediatric Associates, our primary goal is to take care of your child. The difference between medical services is sometimes difficult to understand. As providers of medical care, we do not control these differences. Reimbursement for services provided is based on the coding system (ICD 10 and DX codes) that insurance companies use to describe medical work. You may have had one visit with two services provided. For example, a child has a well visit and is also treated for an ear infection. The well visit and the evaluation and management for the ear infection, are billed as two separate services and a patient balance may be applied to this portion of the visit by your insurance company.

Once the office visit is complete, the ICD10 and DX codes are sent by your provider to our billing department. These codes are then sent to your insurance company for processing and payment. Based on your policy, your insurance company processes the claim and either pays the claim, and/or applies some/all of the balance to patient. An EOB is then sent to you and your provider. Once received, the EOB is then posted to your patient account. If there is a patient balance, a statement is sent out. A patient balance is a result of any combination of the below;

Copay

Copay is a fixed amount you pay for health care service when you get the service. The amount can vary by the type of covered health care service. If your insurance plan requires copays, Northern Virginia Pediatrics is to take the copays at the time of service.

Deductible

This is the amount you owe for health care services before your health insurance or plan begins to pay. For example if your deductible is $1,000.00 your plan won’t pay anything until you met your $1,000.00 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

Coinsurance

Coinsurance is your share of the costs of a health care service. It’s usually figured as a percentage of the amount we allow to be charged for services. You start paying coinsurance after you’ve paid your plan’s deductible. For example if you have met your $1,000.00 deductible and your plan covers 70 percent of the cost, your share will be the remaining 30 percent.

Can I Combine Services?

For your convenience, the provider may combine two types of services at one visit — for example, a Well visit and a Sick Visit. Many factors determine if we are able to do this at a particular visit: how well a medical condition is under control, whether a new more urgent problem is present, and the general health of the patient are all considerations. However, because these are two different services, there would be two separate charges and a copay may be applied depending on your insurance benefit.

How Do You Decide What To Focus On During An Exam?

Providers are taught to examine hundreds of physical signs—from knee reflexes to heart sounds. When conducting an exam, the doctor relies on your child’s personal medical history in combination with any current symptoms or problems. Sometimes, specific symptoms such as a heart murmur or rash will be the actual diagnosis. Your child’s medical history is always the first important consideration.

How Do You Decide What Tests and Services You Should Have?

Providers are specially trained to evaluate the usefulness of tests and preventive services and help you decide which ones are right for your child. We offer advice on immunizations, X- rays, blood tests, and a host of other special procedures. Generally, testing is based on your child’s age, health history, and risk factors. Our guidelines are based on those set by American Academy of Pediatrics and the Center for Disease Control.

Unfortunately, there are hundreds of insurance companies as well as thousands of contracts/policies within those plans making it impossible for providers to know how a claim is processed. As your insurance contract is between you and your insurance company, questions regarding your policy, what is and is not covered, should be directed to them. Questions regarding your bill including demographic and insurance updates can be directed to our Insurance and Billing and Department. They can be reached via phone 703-532-4446 and selecting option 5 or by email. Click here for update form.