Insurance and Billing Info

Updated March 4, 2023

Billing Questions

Insurance Plans We Accept

We work with many commercial and Medicaid insurances, including:

• Adventist Health System Employee Health Plan
• Aetna (excluding Medicaid)
• Avmed
• Blue Cross Blue Shield
• Cigna
• Humana
• MultiPlan / PHCS (Primary Network only)
• Oscar Health
• Sunshine Health
• TRICARE
• UnitedHealthcare (excluding Medicaid)

Please note that there are exceptions or restrictions for some of these insurances, so it's important to check with your insurance company to confirm that we are in-network for your specific plan. You can do this by clicking on the links above to search for our practice in the official insurance directory.

If your insurance determines that we are not in-network, they may not cover the visit, and you'll receive a bill at our competitive self-pay rates.

Self-Pay Rate of $105 (Non-Refundable)

Patients without active insurance coverage or without the appropriate Primary Care Provider listed (if applicable) are required to make a payment at the time of service at our competitive self-pay rates, which are non-refundable. Please be prepared to provide a physical or virtual insurance card listing the patient as proof of active coverage. We will not be able to retroactively submit claims to insurance if the policy is later activated.

The self-pay charge is a simple flat-rate fee of $105 for all visits. We do not charge extra for immunizations, as we are enrolled in Florida's Vaccines for Children program. This program covers the cost of immunizations for uninsured or underinsured patients.

Insurance Eligibility

We will attempt to verify insurance eligibility at the time of service; however, due to the nature of insurance plans, it is the patient’s responsibility to check with their insurance company beforehand to ensure that

1. their plan is active;
2. we are in-network with their specific plan;
3. their Primary Care Provider (if applicable) is set correctly; and
4. the insurance company does not have any other insurance policy listed as primary (coordination of benefits).

We accept secondary insurance.

Deductibles, Copays, & Coinsurance

It is the patient’s responsibility to understand their insurance plan’s deductible, co-payment, and coinsurance amounts, which are set by the patient’s contract with their insurance company and must be paid at the time of service. We may postpone an appointment until payment is received. Common deductibles for an established sick visit range from $65 to $120, depending on the type of insurance and the complexity of the visit.

Newborns

Newborns without active insurance coverage or without the appropriate Primary Care Provider listed (if applicable) are required to make a payment at the time of service at our competitive self-pay rates, which are non-refundable. Please be prepared to provide a physical or virtual insurance card listing the newborn as proof of active coverage.

For commercial insurance plans, you must contact your insurance carrier as soon as possible after your child is born to activate their coverage. This step is mandatory, as we are not allowed to bill the parent's insurance directly. Please be aware that most plans only allow for this step to be completed within 30 days of birth. Otherwise, you may have to wait until the next open enrollment period.

For Medicaid insurance plans, you must contact the Medicaid office at (877) 711-3662 to activate your newborn's coverage and designate Dr. Salvador A. Bou-Gauthier as the primary care provider (PCP). Alternatively, you can go online to flmedicaidmanagedcare.com. You must write down the confirmation number to provide to our office in order to schedule your first appointment.

Card on File Policy

We have implemented a new, convenient payment policy using a Card-on-File program. As you are aware, the current state of healthcare in our market has resulted in significant changes in insurance policies, copays, deductibles, and premiums. Unfortunately, a great deal of the financial burden now falls on the patient as a result. There are insurance plans that require deductibles, copays, and coinsurances in amounts unknown to you, or to us, at the time of your visit. All new patients (except those with Medicaid) will be required to provide a debit, credit, HSA, or FSA card at check-in, and this information will be held securely. The amount that we will charge to the credit card on file will be the financial responsibility that the insurance company determines you are contractually required to pay. This determination is called an Explanation of Benefits (EOB), which is issued by your insurance after they process the medical claim from our office.

Preventive Care & Hidden Copays

Your Preventive Care Visit (“physical” or “well visit”) includes a routine physical exam, immunizations and services such that have been defined by the Patient Protection and Affordable Care Act. For most private health plans, providers will not charge a copay, deductible or coinsurance for preventive services. Please be aware that if you have other health issues, check with your insurance company about what preventive services are covered by your plan.

Even if a preventive test or screen is fully paid by insurance, you may still receive a bill for a copay or co-insurance for the office visit. That is, the preventive care is free, but the doctor’s assessment is not.

• The Preventive Care Visit, which includes a routine physical exam and immunizations does not require a copay.
• If you discuss symptoms of acute problems or chronic diseases at the Preventive Care Visit, it is considered “diagnostic” and you will most likely be required to pay a copay.

Example: You make a doctor’s appointment specifically for a preventive service or test, but during the course of the visit you are treated for an unrelated problem, like allergies or changes in your ADD medication. For this visit you would be required to pay the copay for the office visit.

The decision of charging a copay for a visit is not decided by Dr. Bou Pediatrics; these decisions are based on federal laws and insurance regulations. Complaints of this nature should be directed to your insurance company. 

Other Fees

• FMLA forms- $60
• Immigration and IRS letters- $10

FMLA forms cannot be billed to the insurance. Per the US Department of Labor's Family and Medical Leave Act Employee Guide, the patient is responsible for the cost of these fees.