Answering the Most Common Insurance and Billing Questions

Published on in CHOP Family News

We know that figuring out your health insurance and your bills from Children’s Hospital of Philadelphia can be confusing. That’s why we want to partner with you to make it as easy as possible to understand your responsibilities and to eliminate surprises when bills arrive.

First and foremost: We want to help all families obtain health insurance for their children. If you don’t receive health insurance through your employer — or if that coverage leaves you with unwieldy co-pays or balances — we encourage you to contact our Family Health Coverage Program at 800-974-2125 or fhcp@email.chop.edu. You will be assigned a family health coverage coordinator who will explain what public insurance, such as Medicaid or CHIP, your family qualifies for and help you apply, when applicable.

Before your visit

Whether you have health insurance through your employer or through public insurance, it’s important to make sure that your insurer includes CHOP and your doctor(s) as being “in-network” providers and that the specific service your child needs (office visit, procedure, lab test, etc.) will be covered. Most often the ancillary services, such as labs or X-rays, are covered under the “outpatient hospital” benefit coverage. The most reliable way to find out what is covered is to call your insurance company’s member service phone number and ask if both the CHOP doctor and the outpatient hospital service is covered and “in-network.” Your child can still see a CHOP doctor who is “out of network,” but you’ll be responsible for higher cost sharing.

You may also call the specific specialty division or center where your child has an appointment and ask for the scheduler or financial counselor, who will help answer your questions

For specialty care services, such as seeing a dermatologist or a cardiologist, you may need to get a referral from your primary care pediatrician prior to your specialty care appointment so your insurance will cover the visit and any ancillary hospital services. Similarly, many insurance plans require that you get a preauthorization for these ancillary services, such as some lab tests or procedures, before your child undergoes them.

Even when a doctor or service is covered by your insurance, you may still be responsible for:

  • A co-payment — an amount set by your insurer that is due at a visit
  • Co-insurance — your share of the cost, usually a percentage
  • A deductible — an amount your insurer determines that you need to pay each year before your coverage kicks in
  • Other charges — Visit our Billing and Insurance website for a complete list of insurance terms that may apply to your coverage

How much will your visit cost?

CHOP is committed to being transparent about costs and has launched a new service to help you determine what your share of costs are likely to be for a planned procedure for your child.

Our Patient Cost Estimation Department (PCE) was created because we know families are facing increased out-of-pocket health expenses, especially as high-deductible plans are more common. This information will help you make the best possible decisions for your family.

The PCE staff will work closely with the specialty division where your child has a scheduled appointment to provide a cost estimate for the anticipated services. Please note that the actual cost of a procedure may be higher or lower based on the specific clinical needs of each child.

To reach the PCE, you can send a request through your MyCHOP account or reach them via email at PatientCostEstimates@email.chop.edu.

During your outpatient visit or inpatient stay

Sometimes during the course of an outpatient visit, your care provider may perform a test or administer a shot that will be part of your bill. Depending on your insurance plan, this may or may not increase the amount for which you will be responsible.

For example, you may pay your office visit co-pay when you check in at the Specialty Care Center, then later receive a bill for the co-pay and/or co-insurance for an EKG or X-ray (outpatient hospital ancillary charge) that was performed during that visit.

If your child is hospitalized, there will be physician and hospital bills. The hospital bill will include the charges related to your child’s hospital room, nursing coverage, food, cleaning and whatever ancillary services your child received, such as, but not limited to, medications, labs, X-rays, physical therapists and respiratory therapists.

Understanding your bills

Families sometimes get confused when they get more than one bill from us. Often bills arrive on different days. CHOP has three billing systems that produce three different bills for services your child has received:

  • A BLUE bill reflects charges from physicians, whether your child was seen in the hospital setting or at one of our 50 CHOP Care Network primary or specialty care locations, or a community hospital inpatient unit staffed by CHOP physicians. Any medications given during an outpatient visit with your primary care pediatrician will also be on this bill.
  • A GREEN bill covers hospital services. This is a broad category that includes inpatient stays and outpatient hospital procedures or diagnostic testing (whether they were performed on Main Campus or in a CHOP Specialty Care or Surgery Center location); supplies and equipment; and technical services, such as lab tests and radiology studies. It also includes charges for services provided by clinical staff such as physical, occupational and speech therapists, audiologists and dietitians.
  • A WHITE bill is from CHOP Home Care and covers durable medical equipment, home infusion therapy, and other home care services.

Children’s Hospital and our network of CHOP physicians first bill your insurance, and then deduct your insurer’s payment before billing you for your balance. If you have a question about any of the bills, call the phone numbers in the in the upper left corner of that specific bill.

The future

Further complicating all insurance issues is healthcare reform going on in Washington. If a new law is passed, your coverage may change even if you have the same plan from the same insurance company your family has had in the past.

Be assured that we will be here to help you navigate the new landscape, whatever it looks like, as we continue to provide the best possible care to your child.


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