Health Insurance Basics

Understanding your insurance policy is vital to coordinating your child’s health care. Your insurance policy is a contract between you and the insurance company. Our payment for services provided is also based on a contract between Erika Beard-Irvine MD LLC and your insurance company. We are obligated to report all services provided and to bill for them in accordance with our fee schedules. Much as it would be a contract violation for you to refuse to pay your insurance premium, it is also a contract violation not to charge or to undercharge for services we provide.

Medical offices, hospitals, labs, etc. sign contracts with specific insurance companies agreeing to specific payment terms for our services. That’s what we mean when we say that we are “contracted” with your insurance company. Different plans within a company may have more specific requirements, so even thought I might be contracted with an insurance company, I might not be in network with a specific plan. I always recommend that someone check with their insurance company to make sure I am in network before seeing me for the first time. I am happy to see patients when I am not contracted with their insurance. I can still bill their insurance for my services, but payments might be different than for a contracted provider.

Charges for services provided may vary depending on many factors. Check-ups are billed based on age, but other visits are billed based on a complicated system of time, complexity, number of diagnoses, and medical decision making, therefore charges may not be the same for each visit. In addition, you may be billed for services including (but not limited to) laboratory testing, screening tools, vaccines, procedures, counseling, urgent visits, and after-hours visits.

​While I can often verify benefits through an insurance company’s website, it is a good idea to carry your insurance card with you. It should have your name or the names of your covered dependents, the policy and group numbers, the claims mailing address and phone number, and the co-pay information. You may not be able to be seen without verification of insurance benefits, or you may have to pay out-of-pocket for the visit.

Patient Costs & Financial Responsibilities

Your insurance plan decides which benefits are covered in full, which apply to your annual deductible, and whether or not they will allow the benefit and pay for the service. Your doctor’s office does not make this decision. If your policy does not cover the service, you will be responsible for the full amount. There are three different categories of patient responsibility: Co-pay, deductible, and coinsurance. These usually apply per person, with annual limits for each individual as well as the family as a whole.
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Co-pay is the amount that you must pay up front before seeing a doctor. This is a set fee based upon the type of provider (general or specialist), the type of visit (preventative or sick visit), and sometimes the group in which the doctor practices (i.e. St. Charles vs non-St. Charles).


Deductible is the amount of money you must pay out-of-pocket before the insurance will begin paying toward the claims filed by your doctor’s office. The amount charged toward the deductible is the negotiated rate between your doctor and your plan, not the full amount of charges for the services provided.


Co-insurance is the percentage of the allowed amount, as negotiated between you and your doctor, that you are still responsible for AFTER meeting your deductible.


Many other charges may be applied to your deductible, including (but not limited to) lab testing, prescriptions, procedures and screening tools. Thus you may not even know that you have met your deductible until we verify it for you. Deductibles and co-insurance amounts reset annually.

Many insurance carriers limit what is covered under the “preventative care” umbrella. They may cover your child’s annual check-up without a co-pay and without having to meet your deductible but not cover the developmental questionnaire or hearing & vision screening. I follow the American Academy of Pediatrics’ Bright Futures Guidelines for preventative care, and I believe strongly that these tools are not optional. Some insurance companies, however, do not pay for recommended screenings or preventive care services.

Not uncommonly, when a child comes in for a check-up and has another presenting problem that is dealt with on the same day, the doctor codes an additional charge. One charge is considered the preventative medicine service (the well check), and the other is a problem-oriented service (problem visit). For example, you present for your child’s check-up and ask about a persistent rash he’s had for several weeks. The doctor will perform all necessary well child exam protocols, including growth, development, and administering vaccines, as well as a problem-oriented exam of the rash, including any necessary prescriptions. Alternately, your child shows up for her scheduled well visit but happens to have a fever and a sore throat that day. The same guidelines would apply for any other abnormality or preexisting problem encountered at the well child exam. These types of visits are always coded as two separate encounters, well-child and problem visit. When preventative care became covered without co-pays or deductibles, however, many patients began wondering why they had to pay for the well-child visit. The extra cost often includes a co-pay or payment toward the deductible for the “sick” part of the exam, even on the same day of service as the preventative care. The documentation and billing for these two exams must be filed separately, otherwise it would be considered insurance fraud on our part.

Unfortunately, because of your insurer’s payment policy, in some cases we may have to complete your wellness care and your illness care in two separate visits to allow appropriate billing. Your doctor may also decide that a non-urgent complaint brought up at a well visit would be more effectively managed at a separate visit.

​We urge you to always check the Explanation of Benefits (EOB) that you receive from your insurance company. You will notice several charges. The first is usually the provider charge. Office charges are set higher than insurance companies will pay, to “capture” the highest allowable insurance payment. Second, you will see provider responsibility – this is the discounted part of the fee that my office has agreed to accept when contracting with your insurance plan. Third, you will see amount allowed by benefit. These charges may be paid by your insurance, or may be passed on to you due to a deductible and/or coinsurance. If a charge is “disallowed” the charge will be passed on to the patient directly, the cost and terms of which are confidential between you and your insurance company.

​Health insurance can be confusing, and I am happy to review insurance payments and bills with my patients’ families to help them understand what has been paid and for what they are being billed.