Understanding Well Visit Billing

The Gist:

  • Sometimes there are out of pocket patient expenses at well visits.
  • Some insurance companies make recommended screenings and tests patient responsibility, even when they require them.
  • If your child is sick at the well visit, you may need to reschedule the well visit. You may have the option of treating the sickness and completing the well visit at the same time. If you have both services on the same day, your insurance company may require a co-pay or apply the care for the sickness to your deductible or co-insurance.
  • If there is a new problem to diagnose or treat at the well visit, you have the option of rescheduling the well visit or the care for the new problem, or doing them both today. Your insurance may require a co-pay or apply it to your deductible or co-insurance. They will do the same if you do the visit on a different day. It is usually more efficient and cost-effective for you if we do both the same day.
  • If your child has a chronic condition such as asthma that requires a recheck visit several times a year, we try to combine this with a well visit for you whenever possible. Your insurance may require a co-pay or apply it to your deductible or co-insurance. They will do the same if you do the visit on a different day. It is usually more efficient and cost-effective for you if we do both the same day.

There are many reasons your child may need to see a doctor, but in general they divide into two categories: 1. office or problem-based visits for sickness, symptoms, questions, concerns, or chronic disease, and 2. well visits, also known as checkups, physicals, or preventive visits. These are for routine care, review of history, tests, screenings, measurements, physical exam, early detection of problems, and advice regarding health, safety, and prevention of illness. In children who are growing and developing, these visits are much more important than in adults because missed problems while the body and brain are growing and developing can cause lifelong consequences that could have been prevented.

Many times questions arise regarding billing for well visits. Many insurance companies will tell customers that well care is covered at 100% with no patient responsibility. When the Affordable Care Act was passed, it required insurance companies that were regulated by the law to cover preventive services at 100%. So parents are often very surprised when they get a bill saying they are responsible for charges at well visits. How does this happen? There are several reasons.

Note that these charges do not apply to Medicaid plans since they have no cost-sharing.

Screenings and tests

During well visits, we perform recommended screenings and tests for a variety of problems that may lead to health problems now or in the future. These include vision and hearing screenings, tests for anemia, lead poisoning, and lipids (cholesterol), screenings for autism, developmental delays, teen depression, and substance abuse. Our office only does tests that are current standard of care according to published guidelines and that we agree are essential to keeping children healthy and safe.

Insurance companies require a specific code for each test or screening done. They do this to track what is done, and also to only pay for it when it is really done. They do not want to pay for it at every well visit. They have carefully calculated how much each individual service is worth. Most insurance companies actually require us to do these tests and screenings on their patients. However, these same companies may push the cost of these screenings to your deductible, co-insurance, or completely your responsibility.

These tests tend not to be expensive, but we understand that it is annoying, and sometimes confusing, to be charged several small fees as part of a well visit. Please understand that this is beyond our control and part of our dysfunctional healthcare payment system.

Problem-based care during a well visit

Sometimes we discover a medical problem that requires diagnosis or treatment during the well visit. Other times we may treat an existing medical problem or do the required periodic visit for a condition such as asthma or ADHD while you are here for the well visit. This is much more efficient for you and for us and results in fewer missed days of school and activities for your child. Since insurance companies have determined the exact amount of work and practice expense for preventive care, they require us to code for any additional amount of work done to address a condition or concern. We don’t code for parent questions or concerns or for simple problems. However, we do if a significant amount of work in addition to prevention is required.

It is like any other service: if you add desert to your order at a restaurant, ask the mechanic to also change your oil after fixing the brakes, ask the lawyer to also review your will or the accountant to also do your child’s tax return, there would be additional charges for additional work. Unfortunately, the way healthcare is coded and paid, we can’t make combos or bundle deals or just charge enough to cover everything. The insurance company has calculated the bare minimum they will pay for each service, and require us to basically “nickel and dime” every single little thing we do.

These visits are coded with an office visit code added to the well visit code. Unfortunately, most insurance companies process this office visit code with the typical co-pays, deductibles, and co-insurance. Due to our contracts with insurance companies, in most cases we are not allowed to waive these patient-due amounts.

The alternative to this more efficient method is for you to return to the office to treat any problem that comes up, or if it more serious, to come back for the well visit another day. For chronic diseases that require periodic visits several times a year, like asthma or ADHD, we would have to require you to come separately for that visit. To be honest, we would actually make more money this way because most insurance companies pay less for the office visit when done the same day as a well visit. It would also cost you exactly the same, or more, to do them separately than the same day.

It is not an option to skip one and never do it. Well visits must be completed, and conditions diagnosed and treated. Routine care for asthma and other chronic conditions also must be done. We think it is better for everyone, though we don’t get paid as well, to do them the same day in most cases, unless it is urgent or just too complicated.

There are some things we can’t do the same day, such as complicated visits and some tests and procedures, such as those that are considered surgical.

If you have any questions about these policies or billing for your child’s visit, please do not hesitate to ask.