Insurance and Billing FAQs

Health insurance terms to know

• What is authorization/preauthorization?

  Authorization/preauthorization is when the insurance company is notified in advance of a surgery or hospital stay and is a required notification for most policies for the insurance company to pay for the care. The requirements can differ from policy to policy but the purpose of preauthorization is to notify the insurer or representative so they can determine if a hospitalization or surgery is medically necessary and how many days of hospitalization are authorized. If preauthorization is not obtained, the insurer will deny coverage for an otherwise covered service.

• What is a benefit package?

  A benefit package is an aggregate of services specifically defined by an insurance policy or HMO that can be provided to patients, or the services a payer offers to a group or individual. The package will specify include cost, limitation on the amounts of services, and annual or lifetime spending limits.

• What are carve outs?

  Carve-outs are the separation of a medical service (or a group of services) from the basic set of benefits in some way. In many instances, a different provider will provide the service (e.g., behavioral health is a common carve-out service). The carve-out is typically done through separate contracting or sub-contracting for services to the special population. Increasingly, oncology and cardiac services are being carved out. Many HMOs and insurance companies adopt this strategy because they do not have in-house expertise related to the service "carved out." This process may or may not seem transparent to the subscriber, but it often means that separate UR and pre-certification entities are involved as well as different payers and providers. Carve-outs are also known as sub-contractors.

• What is co-insurance?

  Co-insurance requires the insured to share in the cost of medical care. Under an 80/20 co-insurance provision, the medical expense plan pays 80 percent of eligible medical charges above any deductible. The insured is required to pay the remaining 20 percent. Other co-insurance arrangements, i.e., 70/30 or 90/10, are sometimes used. In the event of large or catastrophic medical expenses, an insured might suffer severe financial hardship due to the operation of the co-insurance clause. To compensate for this possibility, many major medical expense plans contain a co-insurance cap or limit. This provision places a limit on the insured's out-of-pocket costs in a given year. The size of the co-insurance cap generally ranges from $2,000 to $3,000, depending on the plan, although limits as low as $1,000 are sometimes used. Once the co-insurance cap has been reached, all eligible expenses above this amount are paid in full, up to the plan's overall limit of coverage.

• What is a co-payment?

  A payment made by the patient or individual who has health insurance, usually at the time a service is received, to offset some of the cost of care. Co-payments are a common feature of HMOs and PPOs. Co-payment size may vary depending on the service, generally with lower co-payments required for physician office visits and higher payments for emergency room visits and sometimes other hospital care. The co-payment amount is usually determined by the employer so as to ensure the patient has some financial responsibility in their overall care.

• What is a deductible?

  Most PPO plans require participants to pay the full cost of medical services until they reach a certain dollar figure (for example $1,000) before your insurance will make any payments. This is called the deductible. Once you have spent the amount of the deductible in any given calendar year, the health plan coverage kicks in.

• What are definitions, benefits, limitations and exclusions?

  Every health insurance policy or health plan agreement or evidence of coverage is divided into different sections. For instance, a section may identify “benefits” as including services by a physician or surgeon, hospital services, nursing services, medical equipment and the like. This section, in effect, gives a broad outline or index of the benefits covered by the insurance or plan. Sometimes within the same section, but also sometimes in a separate section, there are specific “definitions” of benefits or related terms. For instance, the term “physical therapy” may be defined as “medically necessary therapy ordered by a physician and provided by a registered physical therapist.” The benefit section may list physical therapy as a benefit, as an example, by identifying it as “acute physical therapy.” The term “acute” then may be defined in the policy as being only for a period of 60 days following injury or onset of illness. Then in the “limitations” section of the policy there may be a further qualification of acute physical therapy as only being authorized if it is anticipated that the therapy would result in substantial improvement of the condition within 60 days, or there may be a statement that the therapy is limited to a total dollar amount of charge, such as $500 or $1,000. Further, in the separate “exclusions” section there might be a statement that specifically says that any physical therapy beyond 60 days would be excluded or any physical therapy that would not result in substantial improvement of a condition within 60 days is not a covered benefit. 

  
  

• What is an HMO?

  An HMO (Health Maintenance Organization) is a plan product in which members must access the services of participating doctors, hospitals and clinics in order to have their care covered by their insurance plan. Members typically have full coverage when they stay within their network of providers but no coverage if they choose care out of network. Members may have co-payments but usually do not have deductibles or co-payments.

• Point-of-Service Plan or Point-of-Service Option (POS)

  A product that offers the option to receive a service from a participating or a nonparticipating provider. Generally the level of coverage is reduced for services associated with the use of non-participating providers. Subscribers can select between different delivery systems (i.e., HMO, PPO and fee-for-service) when in need of healthcare services and at the time of accessing the services, rather than making the selection at time of open enrollment at place of employment. The costs associated with receiving care from the "in network" or contracted providers are less than when care is rendered by non-contracting providers. This is a method of influencing patients to use network providers without restricting their freedom of choice too severely.

• What is a PPO?

  In a PPO (Preferred Provider Organization), the plan contracts with physicians and hospitals to provide services at reduced cost. If you use these in-network medical providers, the plan pays most of the cost of treatment but members have more out of pocket costs (deductibles and co-insurance) than an HMO. Participants can use out-of-network healthcare providers, but must pay even higher portions of the cost of care (deductibles and co-insurance).

• What is PSV?

  Pediatric Specialists of Virginia (PSV) is a joint venture with Children’s National and Inova, two highly regarded and trusted medical centers, to provide world-class care for children and families. Through this physician group practice, Children’s National’s talented and nationally recognized teams will provide specialty services in shared settings, combining clinical strengths from both organizations and to make specialty care more convenient for families in northern Virginia and across the region. It offers pediatric Gastroenterology, Nephrology, Genetics, Hematology/Oncology and Orthopedics through this collaboration at three locations in the Fairfax, Va., area.  If opting to use PSV, confirm with your insurance carrier whether your plan participates with this entity since it does not necessarily accept all the same insurances as Children’s National and Inova. 

What to know before you visit the hospital

• What insurance information should I have on hand when I visit the hospital?

  • Name and telephone number of the child’s insurance company
  • Policy holder’s name, social security number, place of employment and work phone number
  • Policy and group numbers
  • Name, address and phone number of your child’s referring physician

• What if my child isn’t covered by insurance?

  If you do not have health insurance, our financial counselors can help you determine if you are eligible to apply for Medical Assistance (Medicaid) and will help you through the process. We also can help you apply for our charity or financial assistance programs. Based on the first letter of your last name, the counselors can be reached at:

  • A-K: 202-476-3326
  • L-Z: 202-476-5505

  Extended payment arrangements may be considered on an individual basis during your consultation. Please contact a customer service representative Monday through Friday, 9 a.m. to 4 p.m., at 301-572-3542. You also can visit the Financial Information Center located in Room 1820 on the first floor of the main hospital.

• What do patients and parents/guardians have the responsibility to do?

  • To provide, to the best of their knowledge, accurate and complete information about all matters relating to the child’s health
  • To the extent allowed by law, to both formulate advance directives and expect hospital staff and practitioners who provide care will comply with these directives
  • To be considerate of other patients and staff and to encourage the patient’s visitors to be considerate as well
  • To pay for services provided, and/or provide necessary information to process insurance claims related to your child’s hospital and outpatient service bills
  • To follow the treatment plan recommended by the practitioner and agreed upon for the patient’s care

• What rights do I have if I am an adult patient?

  If you are an adult patient age 18 or older who has the ability to make an informed decision, you have the right to make your own medical treatment decisions. You also have the right to draft an advance directive giving instructions for healthcare when you are no longer able to participate in treatment decisions. For copies of advance directives prior to your surgery call your doctor.

• What if I am the parent of an adult patient?

  At age 18, children become legally responsible for providing consent for all medical treatments. However, if you or your doctor feel that your child is not able to understand the risks and benefits of medical treatment and cannot make an informed medical decision, a legal guardian must be appointed prior to surgery for that purpose. To obtain legal guardianship over an adult child, parents must apply to probate court in the county where the child lives. For more information, please contact a lawyer or the probate court.

• Who may sign paperwork and consent to evaluation and treatment for a child?

  This information is provided to clarify who may sign paperwork and consent to evaluation and treatment for a child at Children’s National. If you have any questions about this information, please contact your provider.

  • Biological parent. The biological parents are the child’s natural mother and father, i.e., the woman who gave birth to the child, and the man who fathered the pregnancy. Biological parents may sign all paperwork on the child’s behalf and may consent to evaluation and treatment unless a court has determined that the parent no longer has this right. By signing any paperwork at Children’s National, the biological parent certifies that there has been no court action which would prevent them from doing so.
  • Adoptive parent. The adoptive parent is the parent who has been granted adoption of the child by court order. A copy of the court’s approval of the adoption must be provided to Children’s National in order for the adoptive parent to sign paperwork or consent to evaluation and treatment for the child.
  • Foster parent. The foster parent may or may not be able to sign paperwork for the child, depending on which state and county in which the child lives. If you are the child’s foster parent, please contact the child’s social worker to clarify what you are permitted to sign for and to request documentation from the social worker indicating this. You will be required to present paperwork from the county establishing your ability to consent prior to the child being seen or treatment being given. Please also give the social worker’s name and phone number to the child’s provider so that we may contact the social worker directly if questions arise.
  • Caregiver or other family member. The caregiver or other family member may not sign any paperwork on the child’s behalf, nor may they consent to evaluation or treatment unless they provide written authorization to do so signed by one of the biological parents. A copy of this authorization is enclosed for your use. This authorization will expire 60 days from the date the parent signs it.
  • Parent requesting accommodation of a divorce decree. In an instance when the divorce decree changes either parent’s rights to consent to a child’s treatment, Children’s National needs to have a copy of that court decree. The court order may be brought the day of the surgery.

  It is important that you bring any required paperwork referenced above to the child’s first appointment at Children’s National to avoid the need to cancel appointments or procedures.

Questions to ask the hospital about your bill

• Why was my account placed with a collections agency?

  The hospital uses outside agencies to assist with billing and follow up after statements are sent to you. If we do not receive payments, these agencies help us collect the outstanding balance. The most common reason for placement with the collection agency is that we do not have a valid address for you. You can update your address by calling our Customer Service Department at 301-572-3542 or toll free at 800-787-0021.

• Why was my bill sent to the wrong insurance?

  Each time your child is registered at Children’s, we ask that you review your information for accuracy. Changes should be noted on the face sheet. Our staff will update this information on your account and bill the charges to the updated plan. If the information on the bill you receive is incorrect, please contact Customer Service, Monday - Friday, 9 a.m. to 4 p.m. EST at 301-572-3542 or toll free at 800-787-0021.

• What if I cannot pay my bill in full at the time of service?

  Our financial counselors will work with you to set up a payment plan to resolve your outstanding balance. You may pay your bill with a check, money order, cash or credit card. We also accept payments online. 

  Payment plans for balances after insurance can be made through our Customer Service department Monday - Friday, 9 a.m. to 4 p.m. EST at 301-572-3542 or toll free at 800-787-0021.

• How can I obtain an estimate of costs for my child's care?

  Families can use this tool to enter insurance information and look up the estimated costs for appointments and medical procedures.

  Good Faith Estimates

  In accordance with the No Surprises Act, Children’s National can provide a Good Faith Estimate for scheduled visits for uninsured/self-pay patients or upon request.

  You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment and hospital fees.

  You can request a Good Faith Estimate before your scheduled item or service. Please submit your request in writing at least three days in advance of the medical item or service.

  If you receive a bill that is at least $400 more than your Good Faith Estimate for the services identified in the request, you can dispute the bill.

  Make sure to save a copy or picture of your Good Faith Estimate.

• If I have a question about my bill, who can I contact?

  Our Customer Service team is available Monday-Friday, 9 a.m. to 4 p.m. EST at 301-572-3542 or toll free at 800-787-0021 or e-mail [email protected].

• Why are my out-of-pocket expenses based on my outpatient benefits?

  Our physicians are employed by the hospital, so when we submit claims for their services they are designated as “Outpatient Hospital” (even for our Specialty Care Locations) rather than “Physician Office.” As a result, your plan may apply the charges to your outpatient deductible or co-insurance rather than the office visit co-pay.

• What is the facility charge for outpatient visits?

  The facility charge includes costs for running the facility, such as supplies, equipment, exam rooms, educational resources, counseling and staff. It is separate from the cost of the medical provider. 

  Charges are determined based on the type of visit and the hospital resources used during your child's visit. The exact facility charge cannot be calculated until after the medical services have been provided and your visit is finished.  

  Insurance Coverage

  • If you have Medicaid: These programs cover the full outpatient facility charge, so you will not have a balance to pay for the charge.
  • If you have Children's Financial Assistance: This program will cover the outpatient facility charge based on the sliding scale up to 100 percent.
  • If you have commercial insurance: Depending on your plan benefits and deductible amounts, you may be responsible for some portion of the clinic visit charge. Contact your insurance company to find out what your coverage is for outpatient hospital-based clinic charges.

• Why do I receive a statement before the insurance has paid its portion?

  As Children’s claims are submitted, you will receive a statement to let you know the charges have been submitted to your insurance company. Once your insurance company has paid the bill, you will receive a bill indicating the remaining balance that is due from you. Please let customer service know if there are any errors in the information on the statement.

• Why do I receive two bills for each date of service?

  After receiving treatment at Children's National Hospital, your family will receive bills for hospital (laboratory, X-ray, medication, etc.) and professional (physician) charges (this is called the black statement). As a result, you will receive one bill for each date of service as of October 1, 2020.

• What date of service does this bill cover?

  The first statement you receive for both hospital and physician services indicates the date of service. The physician statements will not repeat the date of service as these statements are cumulative – they carry the balance forward for all services previously billed and only new services will reference the date of service. The hospital service will continue to reference the date of service associated with each account.

Questions to ask your insurance provider

• What types of services are generally covered by a group health insurance plan?

  Generally, a comprehensive plan will include the full range of medical services. These may include:

  • Professional services of doctors of medicine and osteopathy and other recognized medical practitioners
  • Hospital charges for semiprivate room and board and other necessary services and supplies
  • Surgical charges
  • Services of registered nurses
  • Home healthcare
  • Physical therapy
  • Anesthetics and their administration
  • X-rays and other diagnostic laboratory procedures
  • Oxygen and other gases and their administration
  • Blood transfusions, including the cost of bloom when charged
  • Drugs and medicines requiring a prescription
  • Specified ambulance services
  • Rental of durable mechanical equipment required for therapeutic use
  • Artificial limbs and other prosthetic appliances, except replacement of such appliances
  • Casts, splints, trusses, braces and crutches

• What if your child has a pre-existing condition?

  Insurers can impose only a 12-month waiting period for any preexisting condition that has been diagnosed or treated within the preceding six months. As long as you have maintained continuous coverage without a break of more than 63 days, your prior health insurance coverage will be credited toward the preexisting condition exclusion period.

  If you have had group health coverage for at least one year and you change jobs and health plans, your new plan can't impose another preexisting condition exclusion period. If you have never been covered by an employer's group plan and you start a new job that offers such a plan, you may be subject to a 12-month preexisting condition waiting period. Federal law also makes it easier for you to get individual insurance under certain situations. You may, however, have to pay a higher premium for individual insurance if you have a preexisting condition. If you have not had coverage previously and you are unable to get insurance on your own, you should check with your state insurance commissioner to see if your state has a high-risk pool.

• Does my surgery/hospital stay need preauthorization?

  In most cases, preauthorization is a requirement for services listed in your health insurance policy. Please review your health insurance policy for details. To get your surgery or hospital stay preauthorized, your health insurance policy should give you the steps for preauthorization. Your health insurance provider will notify you if the procedure or hospital stay is approved or denied. If you are being hospitalized, the specific number of days approved will usually also be provided. 

• Does the insurance company require a second opinion?

  If the insurance company requires a second opinion, it is the parent and/or guardian’s responsibility to obtain one. Your primary care physician can suggest doctors to call.

• What else does the insurance company require?

  Most insurance companies require you to take certain steps before they will cover the cost of a surgical procedure for your child. Every parent should contact their insurance company to ask the following questions:

  • Does the insurance company require a referral from the primary care physician?
  • Does my insurance plan have a deductible?
  • Does my insurance plan require a co-pay?

Outpatient billing

• How am I billed for outpatient visits?

  We also bill a facility charge for outpatient hospital-based clinic visits. This is separate from the cost of the medical provider and includes the cost to run the facility such as supplies, equipment, exam rooms, educational resources, counseling and other staff. Charges are based on the type of visit and hospital resources it takes for your child’s care. The exact charge cannot be calculated until after the medical services have been provided and their visit is finished.

• How can I pay for outpatient visits?

  Medicaid covers the full outpatient facility charge, so you will not have a balance to pay for the charge. If you have Children’s National financial assistance, this program covers the charge based on a sliding scale up to 100 percent. If you have commercial insurance, the portion of what you will be responsible for depends upon your plan’s benefits and deductible amounts. Upon request payment plan options are available by contacting our Customer Service team Monday-Friday, 9 a.m. to 4 p.m. EST at 301-572-3542 or toll free at 800-787-0021 or e-mail [email protected].