True Connections Pediatrics is committed to providing high-quality care for the children in our community. Conversations that are related to billing and collecting money can be challenging. We take the accuracy of billing and collecting payments seriously. We strive to provide services that are fair and convenient to our patients.
The following is a general guide to types of visits and payments to help you better understand insurance. We advise that you consult with your insurance company about benefits and guidelines before making an appointment with us. Although we are contracted with many insurance companies, it is your responsibility to understand your specific insurance benefits.
What is a Co-pay?
This is a fixed amount you pay for health care services when you receive care.
Your health plan determines your co-pay for your visits. If your insurance plan requires co-pays, we collect the co-pay at the time of service. Some co-pays may be billed to you later if the type of visit changes based on care provided or if it was not collected at the time of service. Example: if you have a Well Child Visit and additional evaluations and management services are provided, such as treatment of acute or chronic illnesses, you may receive a bill for the required co-pay later.
What is a Deductible?
A deductible is the amount you may owe for health care services before your health insurance plan begins to pay. For example, if your deductible is $1000.00, you may be responsible for certain health care costs until that amount is met. After that, your insurance plan covers costs more than $1000.00. Not all services are applied to your deductible and this is determined by your plan not us. Some deductibles are a percentage and not a set amount. Deductibles are plan specific and vary. It is important that you understand what is/is not applied to your deductible and if/when you meet your deductible.
Encounter Visit:
There are different types of visits. This is typically not a preventative visit such as a Well Child Visit (check up). These include but are not limited to sick visits, Urgent Care visits (at an urgent care center), acute visits (warts, injuries , chronic medical conditions (asthma, eczema, etc), follow up visits, medication monitoring and refills, and other visits for non-preventative care.
Examples of encounter visits are office visits for a problem such as a fever, sore throat, or vomiting. It could also be for anxiety, depression, or behavioral issues. Other examples are visits to evaluate concerns for ADHD or a visit to manage ADHD medication. Sometimes, we will have you follow up for an ear recheck or weight recheck – these visits are also encounter visits. Each visit will be billed as a separate visit and result in a new charge (also known as price or cost).
The charge of the visit is based on an Evaluation and Management (E&M) code that is determined by the symptoms, diagnoses, and type of information that is reviewed, the risk of the symptoms or diagnosis, and the plan. We are required to follow the coding guidelines and generate a code based on the guidelines. Based on the E&M code, charges are billed to the insurance company. Any charges that are deemed patients’ responsibility are then billed and collected from the patient (parent).
Additional codes are sent if appropriate to cover any in office tests or procedures completed. For example, if your child needs to have earwax removed to examine the ears, there will be a separate charge (or additional cost). If a strep or flu test is completed a separate charge is sent, these may be subject to your deductible and require payment if you deductible is not met. (please see deductible explanation). Depending on your insurance coverage some conditions may not be covered. Example some plans to do not cover services for mental health concerns. Co-pays and deductibles are applied based on the conditions of your insurance.
Nurse Visit
This is a visit during which you will only see a medical assistant or nurse. Examples include visits for immunizations only or only having a New born Screen performed in our office. It does not include a discussion of a new problem or an evaluation from a provider. If the provider is consulted, provides an exam, etc, it is no longer a nurse visit and becomes an encounter visit.
There are E&M codes for Nurse Visits also. A co-pay may be required and/or costs for additional services may be applied to the deductible. For example, even though it is a Nurse Visit, there could be additional codes that lead to additional charges (or costs) to you.
Well Child Visit: Check-Up / Annual Physical / Wellness Exam
This is an office visit to monitor growth and development, advise on common issues that affect that age group, provide anticipatory guidance regarding safety, healthy habits, physical activity etc.
The charge (or cost) of these visits is based on a code determined by the patient’s age at the time of the visit. This charge will cover the interview and exam of the physician. It will often include the costs of all of the procedures and tests that are part of the wellness exam, but not all insurance provides coverage for all services. In some cases, the insurance company does not cover items such as vision or hearing screenings, developmental screenings that are important in evaluating the patient’s overall health. These are important for you to know about and consult your plan regarding coverage. Most Well Child Visits are covered by most insurance companies without co-pay.
The Well Child Visit code and charges do NOT include services that address new symptoms, sick symptoms, and changes to the management of chronic problems (see encounter visit types).
Why did I get charged a co-pay or deductible when I had a Well Child Visit?
Some screenings, procedures, or tests may not be covered under the Well Child Visit codes for some insurances. Additionally, if a patient has sick symptoms, additional problems, new medical issues are discussed, or changes in the management of chronic conditions occur, these are not covered under the Well Child Visit codes and additional services charges are applied adhering to the E&M coding guidelines.
An example is when you, your child, and your provider discuss an acute illness (ex. an ear infection), new condition (ex. migraines), or manage a chronic illness (ex. ADHD) during a Well Child Visit. Medical decision-making for treatment involves more than simply writing a prescription; it involves the providers judgment, knowledge, and time. Well Child Visit codes and the additional E&M code for the additional addressed concerns may be billed as two separate services for the same visit.
To help better understand this, think of working on your car. If you bring your car in for a routine service, you pay for a certain list of services. If at the same service appointment, you ask your mechanic to evaluate and repair a certain knocking sound, you would be charged for that added service, even though it is the same appointment. We know and understand that health care is different from a car repair – both in its importance to you and the way for which it is paid.
At True Connections Pediatrics, we are careful and have multiple processes in place to ensure accuracy regarding coding and billing of our medical services.