Frequently Asked Questions : Novel Pediatric Center
1. What is Direct Primary Care?
Direct Primary Care is a healthcare model focused on putting the patient first. That means treating them when they need it, never rushing patients through appointments, and being proactive with healthcare treatment plans. The doctor-patient relationship is just as the name suggests – direct. Direct Primary Care clinics don’t accept insurance, rather they choose to work directly with the patient.
2. Do you take insurance?
Novel Pediatric Center is an out-of-network provider and does not participate in any insurance plans. However, upon request we can generate a billing receipt that you can submit to your insurer for covered services such as well-child visits, sick visits, vaccines, etc. Reimbursement for out-of- network providers varies significantly from plan to plan. Please consult with a representative from your insurance company for your policy’s details.
How insurance works in the Direct Primary Care program
1. Do you bill insurance plans?
No. Our practice is designed to be unencumbered by the constraints and limited reimbursement from insurance plans so that we may better serve and care for our patients. You will NOT be charged for office visits or co-pays. You only pay the membership fee. Our model results in significant savings: money, paperwork and time. The membership fee allows us to keep our overhead low, our practice small, and work directly for our patients, not the insurance company!
2. Do I still need to have health insurance? Can you see me if I have Medicare or health insurance?
Medical insurance is necessary for patients in the event of an unforeseen catastrophe. Still, many people are finding they can lower the cost of their total medical care by combining a high deductible health insurance plan with a membership-based practice thus making private medicine quite affordable. Expect your insurance to pay for lab tests, mammograms, x- rays, durable medical equipment (DME), and specialist appointments. My services will be covered in the membership fee.
3. As a patient of Novel Pediatric Center, will I still need health insurance?
Yes. we recommend that all patients have, at a minimum, a high deductible health plan (HDHP) . The Direct Primary Care Program is NOT a health insurance program. It is very important to maintain insurance (and/or Medicare) to cover expensive, unusual and unpredictable events such as surgery, emergency care and hospitalization – BUT NOT for everyday preventive primary care. Expect your insurance to pay for lab tests, mammograms, x-rays, durable medical equipment (DME), and specialist appointments. The services of the doctor will be covered in the membership fee.
The current insurance-based healthcare system actually makes primary care MORE expensive, difficult and less effective, too. Our practice does the opposite. By charging a set fee, the doctor can spend more time with you and focus on your individual health needs to maintain and improve your health. The doctor wants you to see her as often as you need to, because her goal is healthy and happy members!
4. What services does the membership cover?
The fee covers excellent primary care through unlimited office visits with minimal wait times, annual wellness exams, well-child exams, sports physicals and school physicals, basic office procedures, treatment of acute illness or minor injuries, chronic disease management, and 24/7 access to your doctor via email, phone, text. Patients will also have access to wholesale labs not included in the membership fees. See our SERVICES page for details.
5. What services are NOT covered by the membership?
The following services are not covered by the membership fee:
- Vaccinations: Not covered.
- Specialty visits, hospital stays, etc: Any medical services from other medical providers will be billed to your insurance by those providers.
- Out-of-office procedures or labs: These, too, can be billed to your insurance by the office administering the labs.
6. What if I need medical attention while I’m away from home?
Naturally we provide such care – yet another freedom we enjoy together as a result of Novel Pediatric Center’s independence from the restrictions of third-party payment. Because we know you well, we can streamline your care when you’re sick away from home. Many illnesses can be diagnosed and treated with a simple conversation by phone, email, text or webcam. We’ll locate the nearest pharmacy and order the medications most appropriate for your circumstances.
7. My child is healthy and only goes to the doctor once a year for a physical. Is a DPC pediatrician really necessary?
Absolutely! Health care today is comprehensive and focuses on much more than just the physical health of your child. The pediatrician is there for you to address the social, emotional and educational needs of your youngster from birth to college. Because you never know when the unexpected will present itself, you need an ongoing relationship with your pediatrician. As your child reaches adolescence, that relationship needs to transition to the child and their doctor, gradually, as we prepare for the eventual moment when he/she leaves for college. In the DPC model, it is very unlikely that you will only have contact with your doctor once a year. You will have the comfort of knowing that you and your older child can contact your doctor at any time for most any reason because your child is an exclusive member of Novel Pediatrics.
8. Does my child have to be a member in order to receive services at Novel Pediatrics?
No. Although membership in the Novel Pediatric Center program offers the best value, children can be seen on a Fee for Service model . Please see the MEMBERSHIP and FEES tab for single- visit pricing.
9. If my child is a member, will I have to pay additional fees for clinic visits?
No. The cost of clinic visits (up to 36 visits per child per year) is included in the membership. You may encounter additional charges for things such as prescription medications, childhood immunizations and certain laboratory tests but you will be informed of any additional charges before the service is provided. You retain the right to decline any services that would result in additional charges.
10. What if my child needs to have an X-ray?
X-ray studies are not performed in the clinic. We are aware of the expense involved in obtaining radiographic tests so we will only request these studies when they are needed to direct the treatment of your child’s medical condition. When radiologic studies are indicated, we will help you get the lowest price for any test your child may need at an external service provider.
11. What happens if my child needs to be in the hospital?
At Novel Pediatric Center, we provide only outpatient acute care and well care services. In order to keep costs low, Dr. Kumar does not maintain admitting privileges at any area hospitals. If your child needs to be treated in the hospital, they will be cared for by the Hospitalist Service at the hospital of your choice. Dr. Kumar will communicate directly with the hospital physician and give them whatever information they need to provide the best medical care for your child. Once your child has been discharged from the hospital, Dr. Kumar will resume responsibility for your child’s medical care.
12. What if I no longer wish to be a member?
You may cancel your membership with the practice at any time and for any reason by giving 30-days advance written notice.
13. If my child receives Medicaid or Medicare benefits, can I submit charges from Novel Pediatric Center to Medicaid or Medicare for reimbursement?
No. In order for claims to be covered by Medicaid or Medicare they must be submitted directly to the plan by a participating provider. Dr. Kumar does not participate in any Medicaid health plans and she will be opting out of participation in Medicare. The beneficiary MAY NOT submit any charges directly to Medicaid or Medicare for services provided by this practice.
14. Do you do sutures (stitches)?
Yes. Although our restraining capabilities are limited, so older children are preferred.