Insurance Confusion. Please read and submit your comments!

I love my job. There are so many things to love, including helping kids get well and watching families grow together. Pediatricians get few instant gratifications, but many overall satisfactions of knowing we make a difference in the lives of children. (Warm heart!)

I knew there would be stresses to my job. All jobs have stress, and I expect things like

• time away from family working on weekends and holidays.
• sleep loss when there are urgencies or emergencies when I'm on call.
• sleep loss when there is a call about a non-urgency. (I do dislike those quite a bit, and yes, they do happen. Please respect our sleep and call during business hours for routine questions.)
• having to give bad news to a family of a very ill child.
• hearing stories of bad social situations and not being able to help immediately.

But one of the biggest stressors for me has nothing to do with the above. It has to do with billing and insurance. I keep thinking that if we educate our parents it will get better, but it doesn't. People who don't know their policy are upset about the charges left to them after the insurance company adjusts the bill and pays their portion.

Source: Shutterstock

During the summer we do a lot more physicals than other times of the year, so the end of the summer through the fall is when the phone call volume really picks up.

• If I knew there would be a charge for the autism screen I wouldn't have done it. Two autistic children recently diagnosed had a delayed diagnosis because parents refused the screen due to cost. Both families said they had no worries so didn't want the screening... so not screening isn't the answer.
• If I knew there would be a charge for the depression screen I wouldn't have let my teen take it. One of these complaints was a parent of a teen with a positive screen. The child was depressed and the parent hadn't suspected it. It is sad that even a positive screening is not worth the cost to a family due to financial circumstances, but every dollar is important for people paying bills. Yes, our health insurance system is broken!
• You should have told me there would be a charge for the ear infection treatment. They usually still want treatment for any sick symptoms. And I did warn them by email and the note posted in the exam room, but they usually say they were too busy to read it.
• I didn't know the lung function test wouldn't be covered by insurance. Neither did I. I don't have your insurance contract.
• I didn't know there would be a charge for ear wax removal. I couldn't see your toddler's eardrum. With that runny nose and poor sleep, it was important to remove the wax to see the eardrum.
• The list goes on...

I think the business of medicine stresses me more than the medicine because it is not what I'm trained to do. We have a business office that handles our billing and collections. I really don't want to get involved in that too much. It is a slippery slope. A big concern of mine is that I don't want to get involved in the billing because I don't want it to alter the way I practice in a negative way. Yes, I need to know the issues so our office can develop procedures to limit costs to families. I do believe that is important. But I don't want to follow medical practice guidelines on a subset of patients who can afford it and not do the recommended care for those who can't. If I do these services only for people who can pay for them (or those who know insurance covers the cost), I am not practicing good medicine for everyone. 

Guidelines are made by committees of well educated people who review all of the data and come up with the best ways to manage various issues. They recommend when we should do things, such as depression screenings, lead screenings, asthma follow up, get an X-ray, use a prescription medicine, and more. If I don't follow those guidelines simply because of cost, I am not providing great care. I only want to provide the best care. 

And if you bring up a concern at a well visit and I remind you that to discuss it might incur a charge to you, am I medically liable for not addressing it when you decide you no longer want to talk about it? It certainly won't get documented in the medical record, which means when you ask about it at a future visit I won't remember you mentioning it before. This can compromise good care because there isn't a good record of symptoms that could have been available if it was properly addressed at the visit. 

Our office really does try to help people with medical insurance issues.

On one hand, we try to limit costs to people. 

• If one drug is usually expensive, we try to order a cheaper option. (But we never know your formulary, they are all different and change often!)
• If I know a referral to a specialist probably won't result in any treatment that I can't offer, I will recommend against it. (If I think the specialist can offer more than me, then I am happy to refer so your child will get the best care. But don't call me when they charged more than you thought they should. Call them.)
• Our office offers extended hours so people don't have to go to the emergency department or urgent care (usually insurance charges you more for those services). 
• I try to talk parents out of vision screening in my office because if their insurance only pays for one per year I want it done by an eye specialist, not me! (See the 2nd scenario for more on this one.)

On the other hand, we try to anticipate and tell people in advance that insurance plans vary, and it is their responsibility to know their plan.

• We have a page dedicated to insurance on our website.
• Each of our well visit pages on our website reminds parents to check insurance.
• Before every well visit all patients registered on our web portal get an email with many important things regarding the upcoming well visit, including insurance issues.
• We have signs posted in each exam room reminding parents that separate issues discussed might incur a separate charge based on insurance.
• I post about insurance issues frequently on our Facebook page.
• I blog about this issue at times. Here. And here. And here. And here. And here. And of course this blog.

Yet the phone calls continue. Parents are upset about the way we charge them for things. This is misleading. Yes, the bill comes from us, but it we are only billing them what their insurance company tells us to.

Health care billing is complicated. We provide a service and apply the standard codes for each thing we do. Each code has a charge attached, based on typical payment for that code. We submit those codes to the insurance company. The insurance company adjusts the payment amounts to what our contract with them states they think are reasonable charges. Some companies allow more payment for one code, less for another. But it's not our choice how much they think is reasonable. We must write off the amount over their reasonable charge cost. The insurance company contracts with its clients to determine how much of each of those reasonable charge costs will be paid by them, and how much is the client's responsibility. We never see those contracts, so we don't know how much you will be billed at the time of service. We send the bill to the family based on what their insurance company tells us. We cannot adjust that amount -- to do so is insurance fraud. Simple as that. I'm not willing to commit fraud to decrease your bill, no matter how much I like you and understand your financial hardship.

Everyone in my office wants to provide good care, so we discuss guidelines and insurance issues in addition to other office policies and procedures on a routine basis. We review our practice for quality. We often hear complaints from staff that they want us to stop doing a recommended screening because they are tired of hearing complaints. But we continue to offer those that continue to be recommended because we care about the health of your child. We want to do what's right, not what's cheap. And I suspect that insurance will become more costly to people as the new plans roll out. Either you will pay a large premium to have more services covered, or you will pay less monthly but be expected to carry more of the load when you use services. 

Request: Please share how you think we can do it better. What are we missing? How can we better educate all of our families without spending the entire visit talking about possible charges instead of your child's health? We can't change the system (though that's the ultimate fix) but I want to know how we can make the system work better for all. 

First Period Q&A with a Tween

Over the years I've talked with many girls about what to expect during puberty. Some of the biggest questions we all have involve the mysterious first period. I have dug into the recesses of my brain to come up with all the questions asked over the years to put all the information down in one place, though I'm sure I've missed a few. (Note: I'm not going to cover the hormones and technicalities of the menstrual cycle. See the links below if you want to review those.)

If you have a daughter starting puberty, please share. Are there any other questions she has? Put them in the comments section and we'll tackle them!

Is there a good way to know when I'll start my period the first time?

You will never know exactly when your period will start, but good clues that it is getting close to time: 

• It's been about 2 years since your breasts started growing. (Remember those first bumps?)

• There's clear, white, or yellow stuff in your underwear sometimes. It can look like dried boogers or just a little crusty stuff in your underwear, but it's not from being unclean or peeing in your pants. Your body is just getting ready for the full cycle of ovulation (when the egg is released) and the period. Your vagina is moistened with a clear fluid that can drain onto your underwear. Another thing you might notice is mucus is released once a month, about half way between your periods when the egg is released from your ovary once you're on a regular monthly cycle. It often begins before the period starts. As long as there is no pain or funny odor, this discharge is normal. Talk to your doctor if it does smell bad or if you hurt or itch in that area.

• Pimples. Pimples are common with puberty (and for years following).  Many girls will notice that the pimples tend to worsen right before their period starts.

I'm too young for a period. None of my friends even have boobs! Can I stop it?

Puberty has such a wide range of normal ages so it is common for one girl to go things much sooner than her friends. Puberty is most common between 9 and 16 years of age (though some girls notice breast buds as early as 7 or 8 years old). The common age for a period to start is between 10-15 years old. If you are outside of this normal age range, talk to your doctor about it because there are many reasons. Some can be as simple as your family tree (when did your mom or sisters start?) but some can be a medical issue that can and should be treated.

And the opposite issue:  All my friends have had their periods for a long time, but I barely have boobs. When will I start?

Again, there is a wide range of normal (see the question above). Some families have a later puberty than others, so it might just be in your genes. There are other reasons that deserve talking with your doctor about, such as being underweight-- which delays puberty, and other medical issues that need an investigation to uncover a cause that might need to be treated. (That sounds like a mystery book, but your doctor will know what to do!)

Bottom line for early or late puberty: 

If you are outside the normal age range, please talk with your doctor. Don't be embarrassed to bring it up! They might either reassure you that things are still okay, or they might help find the reason and get your body the treatment it needs. Some of these can be serious problems, so don't be shy about going to the doctor. This is one reason that a yearly physical exam is especially important until growth is complete -- your doctor can help keep track of a normal growth progression.

How much blood will there be, and what does it feel like?

The amount of bleeding varies from day to day, month to month, and person to person.  It is common for the first 2 years to have irregular cycles, but many girls can begin to predict their blood flow volume pattern after a few cycles. 

Many girls have some pain during their period. The blood flow does not hurt, but as the uterus contracts it can cramp. Like other muscle cramps, there can be pain from period cramps, but the amount of pain varies in different people. Some girls have cramping with every period while others never feel anything. It is easy to take over-the-counter pain relievers (like ibuprofen or naproxen) to relieve pain. Some girls find it helpful to take ibuprofen or naproxen 2-3 times/day (per package directions) starting 3 days before the period is supposed to start to prevent the cramps. Eating healthy foods, getting regular exercise, and sleeping well every night also seem to help. For severe period cramps that keep you from doing what you want (or need) to do, talk to your doctor.

What do I do if I start my first period and I don't have any pads around or I'm not at home?

First, don't panic! Remember that ALL women have periods, so it is nothing weird to adult women (or men, for that matter, since they live in a world with women). Ask a teacher, school nurse, friend's mom, aunt, or whoever is around for help. She will not judge you or get freaked out. Really. 

How long should I wear a pad or tampon?

Pads should be changed if they are visibly full or after 4 hours, whichever is first. (Except overnight.) If left on longer, they start to have a foul odor, and you don't want that!

Tampons should be changed every 2-6 hours, depending on the amount of blood flow you have that day. Tampons come in different sizes for light days, regular days, and heavy days. Don't ever wear a tampon longer than 6 hours because it can allow germs to grow and cause a serious infection. For that reason I don't recommend wearing them overnight.

Once your cycle becomes more regular, you should be able to predict the flow by the day of the period (and time of day, since that often varies too). Use a calendar to track the amount of flow as well as the days of your period until you get it all straight. Either an old fashioned paper calendar or an app designed to track periods can help. (Search for "period calendar" or "menstrual calendar" in your app store if you have a smart phone or tablet.)

What do I do with the pad or tampon after it's been used?

Most pads are disposable. You can roll it up, wrap it in a little toilet paper (or the wrap it originally came in) and throw it in the trash can. (Use a single layer, ladies! Don't be wasteful with a wad of TP!)

If you use re-usable pads, they will have to be washed before the next use. Talk to your parent about where to keep them between uses. 

Many people flush tampons down the toilet, but that can lead to clogged toilets in many sewage systems. Never flush into a toilet that uses a septic tank. Tampons do not break up like toilet paper does and they will clog a septic tank system. If you aren't sure, you can wrap it in toilet paper and throw it in the trashcan.

Never flush a plastic applicator. You can either put it back in the wrapper or wrap in toilet paper and throw it in the trash.

I leaked! Not only am I totally embarrassed that everyone will know, what do I do to clean up my underwear?

When a period first starts, it often comes without warning and underwear can get soiled. Heavy flow days can also cause leakage onto your underwear. If you expect a heavy flow day, you can wear old underwear, prepare with a product designed for heavier flow, and go to the bathroom more often to change the pad or tampon. 

Despite the best techniques, all women sometimes soil their underwear and even their outer clothes. If you can change right away, fresh blood is easier to clean than dried blood. (This goes for just about any spill in the kitchen too, so clean up as soon as you spill!)

If you're at school, go to the nurse's office. She can help and it probably won't be the first time a girl has come to her for help-- really! If you're at a friend's house, see if she has something you can borrow if you don't have an emergency change of clothes. 

In general, cold water to rinse out blood is better than hot. Because blood is made of proteins that change in heat, the heat can "cook" the blood into the clothing and make the stain permanent.  If you have laundry detergent you can put a few drops on the stain and rub it in. If you have a spray or stick stain remover, you can use that. Allow that to soak overnight in some cold water before putting in the regular laundry. 

Basic tips:

• Carry a clean set of underwear (and pants if needed) in a plastic bag to use in case of emergency.

• Carry a stain stick (they sell these near the laundry detergent) if desired. 

• Rinse in cold water as soon as you can.

• Rub stain remover or laundry detergent into the stain and let it soak. Put it in the plastic bag you carry if you aren't home.  

• As soon as you get home put the soiled clothes in cold water (rub in more stain remover or laundry detergent as needed). Allow clothing to soak overnight. 

• After soaking overnight, rinse in cold water. Repeat a scrub and soak in detergent if needed.

• Once you don't see the stain any more, you can wash with the rest of your clothes like normal. 

What about when a pad won't work, like swimming or ballet? Am I too young for a tampon?

Tampons frighten a lot of girls, but they are safe to use as soon as you are comfortable using them. They do not affect your virginity. They simply are a product that will collect the blood inside you so you don't need to wear a pad on the outside. Many girls use one with their first period. Others don't use them at all. It is up to you! 

How exactly do you get the tampon in? 

First, some general anatomy. You need to know what things look like down there. You can use a hand held mirror to look at yourself and compare to this picture. This is a drawing, so you will look a little different, but you should be able to see the basic parts.

Photo source: Shutterstock

Tampons are inserted directly into the vagina. Much like an absorbent sponge, a tampon will gently swell as it becomes soaked with blood. A string allows for easy removal from the body. Tampons are convenient for swimming or exercising and can be paired with a panty liner - a type of thin pad or a regular pad for extra protection on heavy flow days. When using tampons, women should change them every 4-6 hours.  

It's time to change the tampon, but I can't find the string. Did it get lost up there somewhere? 

First: Don't panic! Your tampon is not lost forever! Sometimes the string can stick to the skin between your labia (labeled labium magus and minus above). You might need to feel around a bit. If there's a mirror nearby, you can use it to look. Sometimes going pee can help the string fall down if it is stuck around the skin somewhere. 

If the string really is up in the vagina, you can put your finger into the vagina to see if you can slip the string back out.

If you can't get the tampon out, tell an adult as soon as possible. If they can't help you get it out (or if you don't want them to try) you might have to go to the doctor to have it removed.  

NEVER forget about a tampon that has been put in... you could get a serious infection if you leave one in too long. 

I seem to always get spotting on my underwear when I wear a tampon, but the tampon isn't full of blood yet. Why is that?

There are several reasons I can think of that blood can get on your underwear. The first, of course is the tampon overflows because it was left in too long for the amount of flow you have at that time. But you can tell that when there is no more white showing on the tampon. If it isn't full, there are other reasons to consider.

First, was the blood on your skin when you put the tampon in? If you wipe after putting the tampon in, that can help this issue. Actually, more than wiping, pushing the toilet paper  (TP) up towards where the tampon is (with the string out of the way) can show if there's blood in the area. Repeat until the TP is clean. You can also wipe the folds of skin with a flushable wet wipe (sold near the other feminine hygiene products or near the diaper wipes -- same concept: wiping with a wet cloth works better than dry TP for many issues).

Another cause would be if the tampon is not inserted properly. Be sure it is completely in. Signs that it isn't in also include being able to feel it when you walk or sit. If it is in all the way, you should never feel it.

Did you pee or poop with the tampon in? This can move the tampon enough to let blood leak around it. Try changing the tampon (and wipe after placing it) each time you go to the bathroom.

Why do I need to pee so much when I'm on my period?

Many women gain water weight just before their period. (Have you heard women complaining of bloating? That's the water.) Your body's hormone changes cause this slow gain, and they also cause the release of the excess water back out of your body (called diruresis). This increases urine production. Look at it in a positive light: you have to go to the bathroom often, so it reminds you to change your pad or tampon frequently!

Can you pee or poop with a tampon in?

Short answer: Yes. But if you do, it is possible to have the tampon shift and cause leakage, especially if you have a bowel movement (poop). If it is too soon to change the tampon and you need to go, you can hold the string to the side so it doesn't get as soiled while you go. Wipe carefully so you don't pull on the string-- you can keep holding it to the side while you wipe too for "safe keeping."

My school uniform doesn't have pockets. How can I carry a pad or tampon to the bathroom?

If your uniform is a skirt, you can wear shorts with a pocket underneath. Some girls will be able to wear a tampon with a pad so that when they remove the pad mid-day, they leave the un-soiled pad on for the afternoon. If you're allowed to carry a purse, carry one every day for unexpected first period days and to get in the habit of always having it. You can also talk with your school nurse or a teacher about what other girls do.

I track my periods on a calendar, but there doesn't seem to be any pattern. Why aren't they once a month like they should be?

Once a month is more of a phrase than a reality. A typical cycle is about 21 - 35 days from start to start. Bleeding can be as little as 2 days and up to 7 days. The first 2 years after starting a period, many girls are irregular. After those 2 years, it becomes more predictable. You might be different than your friend, but your cycle should be about the same each month after the first 2 years. It does help if you track your cycles on a calendar or online app. 

My bleeding seems so heavy. I soak a pad within an hour and there are sometimes clumps in the blood. What is that?

If you are having very heavy bleeding, talk to your doctor because you can be at risk for anemia (too low of blood counts from blood loss). This can sometimes simply be your body adjusting to a period, but it can also be from a treatable condition. Your doctor can help you decide what needs to be done.

How long will the bleeding last?

The amount of bleeding and how long it lasts varies from person to person. Some days there will be barely any blood (called spotting because it looks like just a spot of blood). Other days are heavier. Bleeding can last between 2-7 days normally. Again, charting it on a calendar or app can help you figure out your pattern.

How do I keep from getting stinky?

First, be sure to regularly change your tampon or pad. If it goes without being changed, bacteria start to make a very foul odor. You should change pads or tampons at least every 6 hours (except overnight, when the pad can be left on as long as you sleep). This is important to avoid infections as well as bad smells!

You can use flushable wet wipes instead of toilet paper to help clean the area better. If you need them outside of your home you can carry some in a plastic zip lock bag and keep with your pads or tampons.

There are feminine hygiene products with deodorant available, but who wants to smell flowery? Seriously, I don't recommend these because too many girls have an allergic reaction to them and who wants to have an itchy rash in the place you can't publicly scratch?  

Another thing that's important: Wash! Once you go through puberty, your body in general smells more, so it is important to bathe regularly. Don't forget to do a daily wash of all the skin folds between your legs. You can use any soap (avoid fragrances if your skin is sensitive), but be sure to rinse well! Soap that remains between the folds can cause rashes. You can rinse the area by splashing a cup of clean water between your legs a few times. If you have a hand-held shower head available, that makes it easy to rinse the area well. You can also lift a leg so the shower water can rinse between your legs -- but hold on so you don't fall!

Do I need to wear protection between periods?

You might want to wear a panty liner when it is getting close to your next period, just in case you start, but it's not necessary.

How do I know when the next one will be?

Over time it becomes easier to predict. Keep track of the dates of bleeding as well as how heavy it is and any other symptoms. These can include pimples, cramping, mood swings, tiredness, constipation or diarrhea, back pain, sore breasts, bloating, food cravings, or headaches. All of these symptoms can help predict your cycle. There are several apps available on the computer, smart phones, or tablets, many of which are free. I suggest going to your app store and reading reviews to pick your favorite.

How much more will I grow since I started my period?

Growth speeds during the years before your period, then slows after your period. Some girls stop growing all together, but most still grow for the next 1-2 years. Ask adult family members how they grew (if they remember) because growth patterns tend to follow parents and other family members.

What is PMS?

Common effects of PMS include: bloating, cramps, fatigue, moodiness, headaches, or pimples. There are over-the-counter medications that can ease these symptoms. Ibuprofen or naproxen tend to work well. If you have severe cramping and you are expecting your period, you can start the ibuprofen or naproxen three days before your symptoms start. This decreases the pain better than starting the medicine when the cramps start. Some girls prefer wearing loose clothing or using warm compresses on their stomach. Mothers can share with their daughters their own tricks for coping.

My boobs hurt with my periods. Why is that?

Many girls notice breast tenderness during PMS (Pre Menstrual Syndrome). Your hormones are changing at this time and they can cause the breasts to swell. The swelling causes tenderness. You can help minimize this by eating right, exercising, and getting enough sleep (all month long). Caffeine can worsen it, so avoid things with caffeine.

Where can I get more information?

ThePeriodBlog has a lot of great information, including how to insert a tampon, information about your body,  counting your cycle, and more.

My favorite book for girls about puberty is now a series of books. The Care and Keeping of You and The Care and Keeping of You 2 are available from many retailers. I like that they go over everything from staying clean to eating right to the importance of sleep and more.

I rarely hear questions about the hormones or technicalities of puberty, but for more on the menstrual cycle check out All About Menstruation by TeensHealth. (They also include more related topics links at the bottom.)

A good review of puberty, including how it is staged is found on Young Women's Health (Boston's Children's Hospital).

P.S. I'd love to meet you on Twitter. Stop by and say "hi"!

P.P.S. If you've enjoyed this blog, go to the top of the page and enter your email address so you will get future posts direct to your In Box!