Billing and Insurance

East Plano Family Clinic values our patients and our number one priority is to provide our families with the highest level of treatment and services. Our office also feels it is important to work together with our patients to adapt to the changing way healthcare is financed and delivered. The information is being provided to assist your family in understanding the insurance process, financial policies of our office and the obligations and responsibilities of our patient.

Participating or In-Network Patients

Patients are encouraged to seek care from a “Participating” or “In-Network” physician or “Provider” in order to receive the highest level of reimbursement under their health plan. As a participating network provider, the provider has contracted with the managed care health plan or “Network” to provide services at a negotiated fee which is typically less than the provider’s billed charge. The negotiated fee or “Contract/Network Discount” is provided to the provider and patient, in a statement referred to as the “Explanation of Benefits”, upon processing of the insurance claim. In addition to any discount, the explanation of benefits will include payment made by the insurance company, any patient amount owed for the services such as co-pays, coinsurance, deductibles and non-covered services. It is important that patients review these statements carefully to insure claims are paid according to the patient’s benefits and plan coverage. The amount noted in the patient responsibility does not include payments already made to the provider for the services. This would mean if the amount shown in the patient responsibility was already paid to the provider, additional payment should not be due to the provider.

Filing Insurance Claims

East Plano Family Clinic files insurance claims for all health plans in which we participate.

If East Plano Family Clinic does not participate with your health plan, payment is due at the time services are rendered for treatment in the office and the patient must file insurance for reimbursement.

Filing Your Own Insurance

An itemized receipt is provided by East Plano Family Clinic at the time of check out. This receipt is required when submitting a claim to the patient’s insurance company for reimbursement. Most insurance companies require a claim form be completed and submitted to the insurance company along with the itemized receipt. Claim forms can usually be obtained from the employer or insurance company by requesting via the telephone or downloading from the insurance company’s website. The address for submitting claims can typically be found on the insurance card or in the plan benefit booklet provided by the health plan.

Patient Financial Responsibility Statement

We are pleased to service our families by providing quality medical services and assisting in the billing process. However, it is important that our families understand that ultimately the financial responsibility of these services rests between the patient and the health plan. We hope this summary will be helpful in understanding your insurance and obligations.

  • The patient, parent or guardian accompanying the patient is responsible for providing our office with a valid and current insurance card. We must be notified of any changes, prior to rendering services. Patients unable to provide valid insurance information may be required to pay in full at time of service or reschedule their appointment.
  • The patient, parent or guardian accompanying the patient must pay any co-payment and applicable deductible amounts, as directed by insurance, at the time of service unless prior arrangements have been made with our office.
  • The bill will be sent to the health plan on record for direct payment to our office.
  • If insurance has not paid our claim within 60 days, we may expect payment from the patient.
  • If by mistake, the health plan remits payment to the patient, payment should be forwarded to our office along with all the paperwork sent to you at the time.
  • The patient, parent or guardian will remain responsible for any services that are not covered or noted as patient responsibility by the health plan.
  • Some of the reasons health plans may refuse or deny payment of a claim are:
    • The provider of service is not listed as the primary care physician “PCP” for the patient, and/or no referral was obtained or the provider is out of network.
    • Services provided were for a pre-existing illness that is not covered by the patient’s health plan.
    • The patient’s deductible or co-insurance amount has not been met.
    • The type of medical services received is not covered by your plan or subject to a maximum benefit allowance (generally per calendar year).
    • The health plan was not in effect at the time the service was rendered.
    • The patient has other insurance noted as the primary carrier which must be filed first.
    • The insurance company requires the patient to contact them regarding whether or not the patient is covered by another health plan (generally required to update at least annually).
    • Services indicate the patient was seen for an injury or accident. The patient must provide information regarding the accident or injury to the health plan as requested, before the claim will be paid.
    • The patient or dependent receiving the services is not showing as a covered dependent under the health plan.

Please note that payment collected at the time of service may not reflect the full patient responsibility after insurance. Our office is not responsible for any limitations in coverage that may be included in your plan. Should your health plan deny claims for any of the above reasons, you will then become responsible for the bill. It is the responsibility of the patient to pay denied amounts in full. We advise our families to understand their insurance benefits and review explanation of benefits and patient billing statements carefully. If you feel there has been an error, always contact the appropriate party with questions within a timely manner. Patient amounts owed are considered past due 30 days after the date of the initial billing statement. Anytime the patient is aware there will be a delay in payment, whether by the patient or insurance, it is important to notify our billing office of the situation. 

Newborn or Dependent Changes and Insurance

We understand when a change in dependent status occurs it is likely to be a very busy time in our families’ lives. However, it can be very costly to overlook the requirements of your health plan with relation to dependent changes. It is extremely important to understand this process and time restrictions involved.

Upon the birth of a newborn dependent, adoption or other change to a dependent status, you must contact the employer and/or health plan to add new dependents within the time limits defined by the health plan. Most insurance companies require notification of the change within 30 days from the date of birth, adoption or event date. If you already had dependent coverage prior to the birth of a newborn, adoption, etc, please be advised the insurance company will not automatically add the new dependent to the health plan. Failure to add the new dependent may result in a lapse of insurance coverage for the new dependent, meaning all services provided during the lapse time are the responsibility of the patient. Contact the employer or health plan with further questions regarding this process.

Insurance Referrals and Authorizations

Some health plans require insurance referrals or pre-authorizations in order to receive treatment from a specialist or for special services or medications. It is the responsibility of the patient to know their benefits and request the required referral or pre-authorization prior to receiving the services for which the referral or authorization is needed.

Failure to Pay

Continued failure to respond to billing statements or make payments may result in the suspension of certain non-urgent services and ultimately in dismissal from our practice. Please be advised outstanding debts will be forwarded to a collection service where unpaid balances will be reported to the appropriate credit agencies. 
Overpayments and Refunds

Should you feel you have made an overpayment to our office or are awaiting a refund based on insurance reimbursement, please contact the appropriate account representative in our Billing Office with questions. If you are entitled to a refund, our office will issue a refund check to the responsible party listed on the account, upon request. Due to the frequency of visits in pediatrics, if we do not receive a specific request for a refund, overpayments are applied as a credit to the patient’s account and applied towards future visits in our office.

Should you have any questions about this summary or any billing issues, we encourage you to discuss it with our Billing Office. We appreciate your dedication to our physicians and are happy to have your family as part of our practice. We look forward to providing many years of service to your family.