"I Thought It Was Covered?" Why You May Receive a Bill After Your Child’s Well Visit

Dr. Gellner: So you take your child in for a well visit, but then you get a bill from your pediatrician's office. Well visits are covered 100% by most insurance companies. So why are you getting a bill?

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Dr. Gellner: When a parent brings their child in for a well visit, often they want their pediatrician to address other issues. We've all had it happen. I'll have parents come in for a well visit, but then they'll also want me to refill medications or discuss headaches or stomach aches that their child's been having. And sometimes they want to discuss behavior concerns, evaluate for ADHD or depression. The problem is that insurance companies have very clear guidelines about what constitutes a preventive visit, which is how a well-child visit is billed versus what is billed under "E&M coding or evaluation and management coding."

Every insurance company has their own guidelines, but there are some things that are standard across the board, and these are set based on recommendations from the American Academy of Pediatrics and the Affordable Care Act. For example, checking your child's growth, getting routine immunizations, and checking developmental milestones are standard from birth to 5 years old. Screening for autism is now part of a well-child visit at ages 18 and 24 months. Vision screenings start at three, and some blood work is covered, especially if they're screening for medical conditions.

So what is not covered at a preventive visit? That's anything that is an acute or chronic issue. If your child fell and you think they have a broken arm, not covered. If your child takes several medications for asthma and you need refills for all of them, not covered. If your child has depression or anxiety and you're wanting to discuss that and possibly have them started on medications, not covered. All these things that require your pediatrician to ask questions that are unrelated to preventative care, to evaluate those issues, and then manage them however needed, hence the evaluation and management coding I mentioned, not covered.

In those cases, your pediatrician can do one of a few things. Sometimes depending on what is being discussed and how long of an appointment is needed, we might ask you to come back and our staff will help you schedule an appointment to be seen as soon as possible. If your pediatrician has time, they may tell you that they can address these other issues, and they should tell you about how the coding will be done. There are special modifiers that we use with coding to let the insurance companies know, "Hey, we understand this isn't part of a preventive visit, but we're trying to save the family from having to come back for a second visit and get everything done today." If we don't put that modifier in, it could put us in hot water, because insurance companies don't like us to do more than what we're coding for.

Also, as pediatricians, we do a lot of education and evaluating at a well visit, which we often only have a 15-minute appointment for. So if we're spending extra time addressing extra issues, it's not only pushing into another patient's appointment, but we would like to get paid for doing the additional work. Despite how important preventative care is, especially for the youngest patients, insurance companies pay very little to the pediatricians themselves. Pretty much we all knew that going into peds, but our little patients make the job so rewarding. I know I couldn't imagine being any other type of doctor. What other type of doctor can play with babies, talk to their patients about PokÈmon or superheroes, or look for elephants in their earwax? Seriously, it's the best type of practice.

Now, we know sometimes things are unavoidable, like you have a well-child visit scheduled and your child wakes up with a fever of 102 or cold symptoms for instance. In those cases, depending on how sick your child is, we'll often address the acute issue and reschedule the well visit and also use that rescheduled well visit as a follow-up to make sure they're better. If it's just a mild virus, we just carry on as usual with a well visit, because we know kids get six to eight viruses per year, and it can be guaranteed that your child will have one at a well visit at some point. If it's something simple, I'll just document that we discussed supportive care.

Another reason for getting a bill, which is less common, is that you are getting a well visit on your child too soon. This is mainly for children over the age of 3 where insurance only covers one well visit per year. Some insurance policies consider one year from the date of the last well visit. Some consider it one per policy year. But for all insurances, they can only have one well-child visit per year if they're over 3. So if your child already had a four-year checkup, for example, they have to be five before the next one and it has to pass that one year period.

Also, when scheduling well visits, make sure enough time has passed before the next set of vaccines if they're due for vaccines. An example of this is that there has to be at least six months between the first and second hepatitis A vaccines. Your child's pediatrician should be able to tell you exactly when they would be due for the next vaccine in the series.

So if you have any questions about when your child can be seen for a well visit or what all is covered in a well visit, please either check with your insurance company or talk to your pediatrician directly. Most of us know the rules.

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