No co pay for well visits! But then there's the small print...

It is recommended that at least once a year children be seen for a well visit. It is important that your child's doctor see him regularly when well and not just when sick so we have time to get to know him better and keep up with how he's doing. It might seem time consuming and wasteful, but well visits help track growth, development, safety issues, and much more. Your kids need to come in even if the school doesn't require shots or a form. Now that well visits usually don't involve a co pay, they can be free (or included in the cost of your insurance premium), so there is one more reason for you to bring your child in for well care.

For years we have had the poster below in our exam rooms. It explains what it covered in a well visit and what insurance companies might define as extra services that families must pay.

We have a lot of insurance information on our website. We also send a pre-visit email to all patients who have registered on our website portal. This email contains a lot of important information, including billing and insurance issues that commonly come up at well checks. Our parent handbook that is available in each room includes common billing codes and the amount we charge for each. I have blogged about insurance time and time again. 

Sometimes parents are upset to learn that we can't go over the laundry list of problems that day due to limited time. Well visits have a number of things to cover, and there is limited time for any given appointment. We want to spend adequate time on each concern.

If we do have time to address some or all of the additional issues, parents are usually happy for the convenience. But many are surprised that their Explanation of Benefit (EOB) from their insurance company includes a bill to the family.

Why is this?

Insurance has agreed that preventative well visits promote overall good health and save them money in the long run, so they are willing to have their clients have free well care in order to encourage them to go to those visits.

Insurance is also smart and in the game to make money. They know that many people save up questions to ask at the yearly visit to avoid going in at other times. They are fine with that, but they don't think they should foot the bill for it. If you ask about acne, warts, asthma, and more at a well visit, they know those aren't well topics. They want you to pay the same co pay that would have been expected if you made a separate visit for each issue. Makes sense from a business perspective, right? People often call insurance to complain, and get some version of "your doctor's office billed it wrong" and ask us to change the code.

We didn't bill wrong! We coded for work done. Period. What they are saying is that we billed for some "sick" codes that were addressed at that visit and they don't include "sick" codes in free well care. Or maybe the recommended screening test (such as for autism or depression) is something they don't cover. (This is happening less since the ACA mandates, thankfully.)

Some of the issues that have sick codes are easy to separate from the well visit. To me it is easy if there is a new prescription, that could be a stand alone visit. If your child has an ear infection or if we decide to start a prescription for acne, those easily could have been appointments you schedule separately, but got the convenience of covering it at your well visit.

It is more of a grey area when the prescription is simply a refill and we don't spend a lot of time going over risks of the medicine, how to use it, when to follow up, and all the other "stuff" we do with a new prescription or diagnosis. My EHR (Electronic Health Record) just sees that there was a note or prescription linked to that diagnosis and picks up the code to send to the insurance company along with the other codes from the visit. Some refills really are just a formality, such as for an allergy medicine. Others, such as for asthma, depression, or ADHD, really require assessment to be sure it is the right prescription and proper documentation of that information every time there is is a refill. Those that require school paperwork to authorize a nurse to give medicine at school take more time than a normal well visit. Sometimes there's a fine line between the two.

Some issues are very difficult to say are separate from the well visit. For instance, if a child is overweight, there is a code that gets sent to insurance when we document in the EHR (electronic health record) the assessment of overweight or obese (or some version of a growth issue). We must pick this assessment this to properly document our conversation and advice. Maybe this even leads to extra labs to check on cholesterol or diabetes risks. Growth and nutrition should be discussed at every well visit, so this is part of the well visit, but when the growth is abnormal we might spend more time on it. Does it deserve a sick code and separate charge? This is an often debated topic among pediatricians (and with their patient families when parents get billed). I don't know the answer. If we were lawyers and billed on time, I suspect the bill would be higher than a straight forward well check. But we don't bill on time for these type of visits. People expect that a visit is a visit and it's all-inclusive. It's just not that simple.

I sometimes make the decision to simply not document something we discuss. Typically is is a minor issue that I don't think will need follow up, or I presume if it needs follow up it will get documented at that follow up. This can cause frustration though if a parent calls later and the phone nurse has no idea what advice I gave because there's no indication in the chart it was discussed. And it can be embarrassing when the parent comes in to talk to me about it and I've completely forgotten the previous discussion. There are consequences to trying to be nice when I know the family doesn't want to get charged for something...

Summertime = School Physical Time!

Summertime is the time many school aged kids get their annual check ups. In Kansas it is important that high school aged kids do their physicals after May 1st if they want to participate in a school sport. Other kids simply don't need to miss school on their birthday to do a physical. It's also good to avoid our office during sick season if possible. For all these reasons, summer time is a great time to have a well check. So if you haven't scheduled your physical exam yet, it's time to call! Appointments do fill in fast.

Why do healthy kids need to come in? It's recommended that kids have annual screenings for growth, development, injury prevention, and more. Actually there's so much that we are supposed to discuss and do at a well visit that it is impossible to do it all in a standard 20 minute exam. (See Drowning in a Sea of Advice for more.)

To help with this enormous volume of information, we use handouts and our website to share a lot so we can spend time at the visit discussing your other questions. Please take the time to register each of your children on our website so you will get a pre-visit e-mail. This is becoming even more important as we are trying to be your true medical home and provide the best care to every patient with their unique needs.

To register, simply go to www.pediatricpartnerskc.com and click on the "Create an Account" tab at the top of the page and fill in the information. (Note: Firefox seems to be the best browser for our website. If you are using Explorer or Safari and cannot get the site to load properly, try Firefox.)

Once you've registered the first child, it's easy to add family members. See our How To page for details!

By registering each child you will be able to not only receive these informational pre-visit e-mails, but also ask questions to our front office staff or your favorite providers in a confidential password-protected manner, and pay bills online. Everything is confidential and we will never sell your personal information. 

Our pre visit e-mails have age-specific information to consider before your visit. Please take the time to read through it. Each e-mail has a homework section that is especially important. If you do your homework before the visit, you will find the visit to run more smoothly and you will get more out of it.

This summer I am doing a test of sorts. We are including several printables on the pre-visit e-mail to make your office time easier. You can print your patient information sheet if needed (due once/year, usually at the annual checkup, so young children who come more often don't always need these). We are starting a pre-visit questionnaire that will help identify any concerns to address at the visit. I am hopeful that we will be able to cover more of your specific questions if we know you have read the information on the e-mail, so we don't have to repeat all of the standard things. This should allow much better use of time at your visit to address your concerns.

Watch for your pre-visit email and take the time to read it! I hope to see your kids for their well checks soon!

Top 10 Posts of 2013

My last post of 2012 was my Top 10 Posts of 2012. I think I'll keep the tradition going with the Top 10 of 2013.

photo source: Shutterstock

This past year I have written about everything from insurance to illnesses to common parental concerns. My most influential blog has been about the generic formulations of Concerta, with 11,875 readers. It has been shared on ADHD blogs, various Facebook and Twitter feeds, and found on Google searches. I never thought over 1,000 people would read one of my posts, let alone over 10,000! Thank you to all who are reading and sharing!

If you don't want to miss a post, be sure to sign up for an e-mail subscription on the right!

From #10 to #1:

10. My Child's Cough and Breathing Sounds Like… is a collection of videos I compiled to help parents describe their child's cough.

9. Allergy Tips reviews ways to avoid allergens when possible and how to treat symptoms.

8. Flu Vaccine 2013: The Story Unfolds discusses how coding and billing issues impacted our office use of flu vaccines this season.

7. But the Snot Is Green… once again argues why the color of mucus does not make the diagnosis of bacterial sinusitis and gives information on treating colds and coughs.

6. To Tamiflu or Not to Tamiflu  might be a little intense for some readers because it reviews the research on Tamiflu risks and benefits. I am happy it is among the top 10 because I want people to see that Tamiflu isn't that miraculous of a drug for influenza. I get far too many requests for it this time of year. 

5. Flu Shot Information 2013-14 Season explains the different types of influenza vaccine available for the season. 

4. Help! My Child Has ______ Up His Nose! shares a "secret" tip I use to get some unwanted objects out of a child's nose. 

3. Screen Free Week is a challenge to readers to go Screen Free for a week. I have no idea why it is ranked so high. That is a surprise to me. 

2. Cough Medicine: Which One's Best reviews various cough medicines and other treatments of cough.

1. Generic Concerta Not Working Like the Brand Used To?  was read about 10 TIMES as much as any other post. It was found most often by a search engine, not direct shares, which tells me that many families are struggling with this issue. This is the post I am most passionate about. Any of my ADHD patients who are treated with Methylphenidate ER/Concerta know how angry I am that the FDA allows this substitution. I am thankful that the blog can help spread the word so that parents who are concerned about their child's sudden altered response to a medication can learn what might be the cause. I had so many updates to the original post, I wrote a follow up: Update on generic Methylphenidate HCl ER.

Blogs that missed the Top 10 that I wish more people would read include: 

Evolution of Illness - I wish people would read this because we often fall into the trap of wanting a quick fix. Too many parents bring kids into the doctor for a fast remedy only to find that there isn't one.  Resolution of illness takes time. Sometimes kids get worse, only to have the parent accuse a doctor of missing something. It happens to all good docs once in awhile…

First Period Q&A with a Tween - I wish people would find this one because it has questions every young lady thinks about but is often afraid to ask.

It's [Sports, School, Camp, Yearly] Physical Time - I wish people would read this so they understand the value of well exams and the scheduling constraints most pediatricians face. Don't call at the last minute!

Insurance Confusion - I wish people would read this because dealing with insurance is one of the most stressful parts of my job. I want people to learn about insurance to avoid financial surprises and to be responsible with insurance use.

Private Discussions with the Pediatrician - I wish people would read this because I am often uncomfortable (and sad for a child) when a parent wants them to leave the room for us to discuss something privately. Pre-planning with a quick phone call or secure message before the visit can save the child from excess worry.

What kids need to be able to do to leave the nest - This is one of my favorites because it was written at a very emotional point of my life. My kids are growing up and I reflected on what I really want them to know.

New Ideas

While most of my blogs were article-style writings, I introduced a few different types of blog this year. 

My first (and to date only) attempt at a video blog was Nutrition For the Picky Eater. It was born from a talk I gave at an ADHDKC.org parent meeting. 

I also did a picture blog with Lawn Mower Safety. 

I had one guest blogger. Sleep expert, Kerrin Edmonds, wrote Common Sleep Myths. 

Busy times…

April was my busiest month blogging. Seven posts that month. It tends to be a slow month in the office.  Ironically it was also Screen Free Week, a time I should have been off the computer!

• Allergy Tips

• Generic Concerta Not Working Like the Brand Used T...

• Screen Free Week April 29-May 5, 2013

• Help! My child has ___ up his nose!

• Group Teaching With Physicals

• Waiting times...

• Feeding Your Newborn

It's [Sports, School, Camp, Yearly] Physical Time!

It's that time of year when school aged children and teens need physicals for school or camp entry or to participate in sports. Parents often want to work in a last minute "quick physical" for a form to be signed before a sport season starts or a child goes to a new school. Plan ahead so you can get an appointment at your preferred time!

Unfortunately some parents calling at the last minute are unable to get an appointment that fits their needs so they decide to go to a walk in clinic to just get the form signed. Keep reading to learn why this isn't a good substitute for a yearly physical in your child's medical home (AKA regular doctor's office).

Some parents don't think a yearly physical is important, and if not required to present a form to a school, sport, or camp, they simply don't do them. Their kids miss out on the benefits of a yearly physical.

Even when you think your child is healthy, there are several things that should be discussed, reviewed, and evaluated during the physical, so the visit isn't quick and it should be done in your child's medical home. If your child's regular physician is not available, there is still benefit to scheduling with another provider at your doctor's office as allowed by their policies. Past records are available to be able to compare current height to past growth. We can review vaccines and update as needed. We can update your child's record as needed since the last visit with new family medical history, changes in the home or school, and with your child's overall health.

Over the years I have "cleared" many student athletes by signing a pre-participation form required for high school sports or camps. On occasion I have not been able to sign the form, and this can lead to frustration for the athlete and his/her family.  If a physician or other licensed medical provider does not feel requriements have been met to "clear" an athlete for safe participation in sports, parents and their athlete often do not understand the "why" behind the need for further evaluation or treatment.

Common reasons to not clear an athlete for participation include recent concussion or a history of passing out that hasn't been fully evaluated.  I had one patient upset that I wouldn't sign the form because of a current broken bone... you can't play a sport in a cast! From the mother's perspective, she just wanted the form done today because the physical was today. From my perspective, the form can be signed when the child is able to play. I can't in good conscience say the student is able to play today if he is not. You don't want me as your child's pediatrician if I am able to attest to something I know is not true.

Please don't go to an urgent care or chiropractor to get the form signed when your regular doctor refuses due to a medical concern. I have seen parents do this -- omitting the fact that their child has passed out and needs further testing or had a concussion. That undermines the reason for the form in the first place! It is for your child's safety!

A glance at the Kansas Pre-Participation Physical Evaluation form's first page highlights many of the important topics to investigate. It would be impossible to completely cover every recommended topic at every physical, but standard recommendations include:

• Review of health history, including chronic conditions (such as asthma, diabetes, learning disabilities etc), hospitalizations, surgeries
• Review of family medical history
• Height, weight, Body Mass Index (BMI), vital signs (blood pressure, pulse, respiratory rate) - comparison to previous values is most helpful
• Puberty status
• Nutrition, exercise, and weight management issues - including performance-enhancing substances
• Sleep
• Risk factors (safety, smoke exposure, violence, alcohol use, screen time, internet safety, and more)
• Mental health (depression screening, drug/alcohol use, bullying)
• Physical exam (special attention to cardiac system, musculoskeletal, neurologic and other sport's preventing problems)
• Update vaccines as needed
• Laboratory evaluation as needed: cholesterol screening, anemia screening, and other risk-based testing

Not included in this list is following up chronic conditions, addressing the issues raised at the physical, refilling all medicines, etc. There are times that addressing one or two specific issues is appropriate, but often there isn't enough time to adequately address all concerns. A separate visit may be needed to be able to devote appropriate attention to each issue. Please don't save up a year's worth of concerns to discuss at one visit each year. 

A well visit is recommended every year for all children over the age of 3 years (more for younger children). If your child hasn't had a well visit in the past year, call today or request a physical through our portal! Don't wait until the last minute... summer physicals book quickly.

The yearly well visit can be used to address all sports and camp physical forms that need to be done. Please bring them to your visit with the appropriate sections pre-filled out to save time in the office.

Group Teaching With Physicals

Around the country the idea of group physicals has been gaining momentum. A recent article in Everyday Health "Group Appointments With Doctors: When Three Isn't a Crowd" explains it well. Before you get creeped out thinking of the doctor examining everyone in a big room, everyone still gets a private exam. The benefit is getting more detailed information and sharing questions with others in a similar interest group.

There are so many teaching points to discuss at annual well visits that it is impossible to fit them into a typical 15-20 minute appointment. If you're really interested in the recommendations (and I will admit I fall short on addressing every one of these sundry things at standard visits and still won't be able to fit them all into the group visit) they are found on Bright Futures.

A solution many doctors are finding helpful to cover more topics is to do a group teaching session to review all the nutrition, safety, development, and vaccine information, then break into individual rooms for history taking, vitals, vaccines, and exams. This eliminates the repeated advice and instruction for separate patients, allowing more to be discussed with a group of patients and still allow time for individual exams.

The benefits to patients are many:

• More information shared in a comprehensive manner
• Start on time!
• Individual time with the nurse and physician 
• Potential to learn from others in the same age group (from discussion/questions raised)

Since summer walk in clinic tends to be slow and many teens need physicals before school starts, I think the opportunity is presenting itself to have a Saturday morning session. Although it is hard to know exactly how it would pan out, I expect that the entire time will be about an hour (which is about the same time for a standard well visit, but less time waiting). Some kids would check in before the discussion to have their vitals and exam, others would arrive for the session and have the exam afterwards. This would allow everyone to be there less overall time, with more information shared. This venue does NOT allow time to be devoted to other health issues, such as chronic illnesses and prescription refills. People who wish to discuss a laundry list of things will be asked to return for a separate visit to be able to devote appropriate time to issues. (This applies to standard well visits as well since each topic can be given its own importance at a separate visit.)

If your teen(s) (13-18 years) would like to participate in this pilot project, please call the office to get on a list of interested people. Be sure to let staff know any blackout dates you can't attend. I will assess how many people are interested, available dates, and ages of the interested teens to offer a few dates for appropriate ages. If your teen already has an appointment scheduled, my staff can move them to the group visit easily.  At the end of the session you will be asked to complete a survey about the concept and the work flow of the visit.

If this idea works out, I will add other age groups.  I think newborns would especially benefit, because they could follow with the same group as the kids age, allowing them to form bonds with other families and get support for all the concerns of their age group.

Call the office soon if you're interested!