Billing & Insurance

Prairieville Family Hospital (PFH) accepts all major private insurance plans such as Aetna, Humana, United Health, Cigna and BlueCross/BlueShield. We also accept out-of-pocket (self-pay) payment in the form of cash, checks or major credit cards. Your ER co-pay will be collected at the time of your visit. We will then bill your insurance company for the policy’s emergency room benefits. There will be two different claims mailed to your insurance company: the facility bill and the physician bill. If you have any questions concerning your bill, please contact us.

PFH understands that insurance and medical billing is a confusing and overwhelming process for all of us. The system inherently limits access to accurate information about the costs and reimbursements associated with medical treatment.

Recent legislation to bring transparency to billing for healthcare services has finally been enacted. This will provide our community the opportunity to make informed decisions about costs when seeking healthcare services. Hospitals and doctors will have a better understanding of the insurance company’s average reimbursement for healthcare services in our market. Patients will finally have visibility to the pricing of the healthcare services that are provided.

PFH will continue to provide the most competitive prices in the market. These industry changes will confirm that our current business practices have resulted in patients paying much less out of pocket for healthcare services at PFH than at any other hospital in the region. We are thankful that this new legislation will bring transparency and accountability to the insurance billing process. We are in the process of updating our charge master based on these new regulatory requirements.

1. Copay is a charge set by your health insurance plan for specific services. Your copay is due at the time of service and varies for different services. For example, a visit to your primary care doctor will be different from a visit to the emergency room or a specialist. Your copay amount is typically based upon your specific insurance plan.
2. Coinsurance is the amount you are responsible for after you have paid your copay and met your annual deductible. Coinsurance is typically done with a percentage of covered costs. After the deductible is met, your insurance will pay a percentage of the balance. Example; if your insurance pays 80% of the covered services, you are responsible for 20% of those charges.
3. Cost-sharing is the general term for any charges the patient is responsible for under the terms of their healthcare plan. This includes copayments, coinsurance and deductibles. Most healthcare plans include a maximum cost-sharing amount that sets an annual maximum out-of-pocket limit to the financial responsibility of the patient. See your specific health plan for details.
4. Deductible is a set dollar amount that your insurance company requires you to pay out-of-pocket (yearly) before your insurance provides payment of claims. The amount of your deductible is based on your specific health plan. Not all plans have a deductible.
5. Explanation of Benefits (EOB) is an overview of the medical services you received.
   • Amount billed – the cost of services (charges) by a provider or facility submitted to your insurance company.
   • Allowed Amount – the amount of money your insurance company has determined is reimbursable to the provider or facility for medical services.
   • Paid Amount – the amount of money paid towards the “allowable amount” by your insurance company.
   • Patient Responsibility – any unpaid portion of the “allowable amount” that was not paid by your insurance company due to the patient copay, deductible and coinsurance that was not paid..
   • Balance Bill – this is the remainder of the amount billed (charges) that were “not allowed” plus any unpaid “allowed amount” by your insurance company. PFH will never bill you for balances of charges that are “not allowed,” but we will bill you for unpaid “allowed amounts” that your insurance company has cost shared to you.

For all cases deemed emergent, Louisiana state law requires your insurance company to pay for your emergency care — even if the emergency room is classified as out-of-network. The state of Louisiana empowers patients to use a standard called the “prudent layperson standard” when determining what constitutes an emergency. If your insurance provider refuses to reimburse you for your emergency room visit, you may file a complaint with the Louisiana Department of Insurance (LDI). For more information about this process, visit the LDI website.

For decades, insurance companies have dictated the cost of care. Until this year, the insurance companies did not share publicly or privately what they reimburse for services. Doctors and hospitals had to blindly negotiate contracts with insurance companies without knowing the actual market value of the services being provided. As such, some doctors and hospitals chose to stay “out of network” if they have reason to believe the “in network” reimbursement is undervalued and unfair. Reimbursement is then negotiated “out of network” after services are provided. Not knowing what the insurance companies’ “allowed amounts” are, the initial charges are high so providers and facilities can negotiate a fair value for the services provided. PFH will never expect you to pay beyond your “in network” benefits and “allowed amounts.” PFH will never balance bill you for charges “not allowed” by your insurance company. In fact, PFH can offer additional savings through our Prompt Pay Program and continue to be the most affordable hospital in the surrounding market. We are in the process of updating our charge master based on these new regulatory requirements and we will continue to update it as we receive more information.