Financial Policy

We would like to thank you for choosing Commonwealth Pediatrics. We are committed to providing you with the best possible care. Please review and sign the following, either on the form or the office signature pad.

Responsibility for the bill

It is the expectation that all patients/guarantors receiving services are financially responsible for the timely payment of all charges incurred. While the practice will file verified insurance for payment of the bill(s) as a courtesy to the patient, the patient/guarantor is ultimately responsible for payment and agrees to pay the account(s) in accordance with the regular rates and terms of the practice in effect at the time of the appointment.

Copays and healthcare laws

Commonwealth Pediatrics would like to advise you on how health care reform may affect your copays at routine physical exams and sick visits. The healthcare law states that patients will no longer have to pay copays for routine physical exams. Some insurance plans are grandfathered in, meaning a copay is still required for routine physical exam visits. If your insurance plan requires you to pay a coinsurance or a deductible, you may be billed for this balance.

However, copays and deductibles are still required for other services. If your provider addresses a specific health issue beyond the routine physical exam, there will be an additional charge added for the treatment of the illness, and you will be responsible for the copay portion of that visit. A routine physical exam does not include a medical problem that is happening now. Please review the following examples for clarification:

• An infant comes in for a routine physical exam and immunizations. The infant also has a cold and fever, and is found to have an ear infection requiring antibiotic treatment. The provider will bill for the routine physical exam PLUS an additional charge for the ear infection, and the parent will be responsible for the copay on the ear infection charge.
• A child is seen for a routine physical exam. The child has asthma and the provider determines the asthma is not well controlled. The provider changes the patient’s medications and provides a new asthma action plan. The provider will bill for the routine physical exam plus an additional charge for asthma management, and the parent will be responsible for the copay on the asthma charge.
• A child with a history of asthma comes in for a routine physical exam. The provider asks about the child’s asthma and finds it is well controlled on the current medication; no changes are needed. There will be no additional charge beyond the routine physical exam, and no copay is required.
• Newborns are seen multiple times in the first few months of life. Well visits typically do not incur a copay, but “weight checks,” “jaundice,” or other problem-specific follow up care is considered an office visit and may incur a copay and/or deductible payment.

Acceptance of insurance

Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. We cannot bill your insurance company unless you give us your insurance information. Please bring a copy of your insurance card to every visit.

We understand it takes time to obtain accurate health insurance information for a newborn. However, if this is not listed correctly by the time your child is 4 weeks old, we retain the right to reschedule well visits to a date when the insurance has become active. We will always provide vaccines to a child regardless of ability to pay.

Our office cannot always tell you in advance whether charges will be covered by your insurance plan. Each insurance company has multiple plans that vary with employer group contracts. Please be familiar with your own plan, including types of coverage and any restrictions on x-ray, laboratory, and emergency room use.

While our staff is trained to assist you, coverage limitations and policy restrictions can only be addressed by your employer or group health administrator. Although our assistance is available, we cannot act as a mediator on your behalf.

We run insurance eligibility prior to every visit. However, ensuring your insurance is eligible, active, and listed with the correct primary care provider (PCP) in our office is your responsibility.

• If you have commercial insurance that we do not accept, or your commercial insurance is inactive, you will be considered a selfpay patient, and full payment is expected at the time of service. Alternately, you may choose to reschedule your appointment to a later date when insurance has been corrected.
• If you have a Medicaid insurance plan, please be advised that we only accept Tufts Health Together with Boston Children’s ACO as the primary insurance plan. You must be listed with this plan AND have one of our providers listed as your primary care provider (PCP) in order to be seen. If this insurance is listed incorrectly, you will be asked to call the insurance plan to correct the information and obtain a reference number before you will be seen. If your Medicaid insurance plan is active, we may not list you as a self-pay patient. Alternately, you may choose to reschedule your appointment to a later date when insurance has been corrected. In addition, we do accept MassHealth Standard as secondary insurance. Please discuss this with our office manager or billing team if you have questions or concerns.

Coordination of benefits

We will submit any non-covered services and/or deductibles to your secondary insurance, provided we are contracted with the payer. Primary insurance copayments are expected and due at the time of service.

Minor patients

The adult accompanying a minor and the parents/guardians are responsible for full payment at the time of service. We are not a party to any legal agreement between divorced or separated parents.

Motor vehicle accidents & workers’ compensation claims

Motor vehicle accident claims must be billed to the auto insurance carrier. At the time of check-in for the appointment, please be prepared to provide workers’ compensation claim number or auto insurance policy info, the date of injury and:

For workers’ comp:

• name, address, and phone number of employer,
• immediate supervisor, and
• workers’ compensation insurance carrier PLUS claim forms

For motor vehicle:

• date and location of accident,
• auto insurance policy info, and
• other party’s auto insurance policy info (if charging to this insurance) PLUS claim forms

Behavioral assessments & developmental screenings

In accordance with federal law and American Academy of Pediatrics guidelines, we offer early and periodic screening for behavioral and developmental health problems at all well visits. These screening questionnaires allow us to provide your child with the best possible care, are required by the State of Massachusetts, and are covered by most insurance providers. Please be advised some insurance companies do not fully cover this assessment and you may incur a coinsurance or deductible amount for the screening.

Routine vision & hearing exams

We also perform routine hearing and vision assessments on our patients. These services may or may not be covered by your particular insurance plan. You may also incur a coinsurance and/or deductible balance for these services. If you do not wish to receive a hearing or vision exam, please inform our staff before your visit.

Travel vaccines

Special vaccines may be needed for international travel. These may or may not be covered by your insurance plan. We recommend contacting your insurance company to inquire about coverage and/or deductibles for these services prior to your appointment.

Point of service collections

Payment for service is due at the time the service is rendered, and non-emergency services may be deferred until the necessary payment arrangements have been made. Payment will be accepted in cash, check, MasterCard, Visa, American Express, or Discover. Patients unable to comply with the point of service payment policy will be referred to our billing department for necessary arrangements.

Patient responsibility

All patient account balances are due within 30 days of the insurance payment, unless other satisfactory arrangements have been made with the practice. Not all services are covered by all insurance companies. It should be understood that, by accepting the service(s), the patient/ guarantor is responsible for payment regardless of whether the insurance covers the service. The practice cannot become involved with any third-party liability matters and must look to the patient/guarantor for payment of the bill. According to your insurance policy, you are contractually obligated to pay any copay due at the time of service.

Outstanding bills

The practice reserves the right to request deposits or payment in full for any outstanding balances. Deposits will be based on the outstanding balance plus the patient’s share of the bill for the new service(s) to be performed.

Payment arrangements

The practice will make a reasonable effort to assist patients/guarantors in meeting their financial obligations. If unusual circumstances make it impossible for you to meet the terms of this financial policy, please discuss your account with our billing office at 978-322-0778 to arrange a payment plan. This will avoid misunderstandings and enable you to keep your account in good standing.

Returned checks

Any payment made by check that does not clear your bank account will result in a fee for insufficient funds in the amount of $25, and will be added to your account for each returned check.

Bad debt/legal action

If your account is not paid in full or satisfactory arrangements made within the allowable time frame, the practice reserves the right to refer the account to an attorney and/or collection agency for collection of the balance. In the event this occurs, you will be responsible for all legal, attorney, and collection agency fees in addition to the principal balance owed.

Patient records, correspondence, and forms completion

Copies of medical records are available to the patient, parent, or legally appointed guardian, after we receive a signed release. Forms and other correspondence are completed at patient/family request. These are free of charge to the family. Please allow 10 business days for completion of all requests.

Release of information

By signing this release of information, I recognize I have received and understood the aforementioned information and authorize Commonwealth Pediatrics to furnish information as necessary to insurance carriers and/or third party payers.