WELCOME TO OUR PRACTICE
Kids Choice Pediatrics was established in 2005 in order to provide exceptional pediatric care to the families in Seymour as well as other surrounding communities in east Tennessee. Dr. David Mendez (Dr. Dave) and Dr. Jill McDowell-Newsome (Dr. Jill) offer over 30 years of combined experience, not to mention personal experience as parents themselves. With the assistance of Kristi Rutherford, CPNP (Miss Kristi), we strive to offer you the best care for your child(ren) and hope you will give us an opportunity to serve you and your family. If you are expecting and would like to schedule a free consultation to come meet the providers and tour our office, which includes colorfully decorated exam rooms, please call (865) 577-6475.
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Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an
in-network hospital or ambulatory surgical center, you are protected from
surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs,
such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to
pay the entire bill if you see a provider or visit a health care facility that isn’t in your health
“Out-of-network” describes providers and facilities that haven’t signed a contract with your
health plan. Out-of-network providers may be permitted to bill you for the difference between
what your plan agreed to pay and the full amount charged for a service. This is called “balance
billing.” This amount is likely more than in-network costs for the same service and might not
count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is
involved in your care—like when you have an emergency or when you schedule a visit at an in network
facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out of network
provider or facility, the most the provider or facility may bill you is your plan’s in network
cost-sharing amount (such as copayments and coinsurance). You can’t be balance
billed for these emergency services. This includes services you may get after you’re in stable
condition, unless you give written consent and give up your protections not to be balanced
billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain
providers there may be out-of-network. In these cases, the most those providers may bill you is
your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia,
pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist
services. These providers can’t balance bill you and may not ask you to give up your protections
not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance
bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also
aren’t required to get care out-of-network. You can choose a provider or facility
in your plan’s network.
When balance billing isn’t allowed, you also have the following
• You are only responsible for paying your share of the cost (like the copayments,
coinsurance, and deductibles that you would pay if the provider or facility was in-network).
Your health plan will pay out-of-network providers and facilities directly.
• Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in
advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in network
provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services
toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact Amber Keeble, Office Manager, by
way of email at firstname.lastname@example.org.
Visit cms.gov for more information about your rights under federal law.