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...

Waiting times...

No one likes to wait at the doctor's office.

We don't want patients to have to wait.

We want to get home to our families at a decent hour each day.

Thankfully our waiting room doesn't usually fill up as above. (This is a screen shot from our Harlem Shake video.) Since our move to our new location, we have fewer people showing up late ~ amazing what a convenient and open parking lot can do ~ and this has contributed to our being on time more often.

Unfortunately there are always things that can come up unexpectedly in our schedules. We can be running right on time, but one patient is all it takes to fall behind. Please be patient! Remember that if it is your child that needs the extra time, we will take that time. We do respect your time and know that it is important, so our office will also accommodate patients as needed. If one provider is running behind, another will offer to see your child if that will help everyone be seen more quickly.

If it is important to you to have less of a wait time, avoid late morning or late afternoon appointments (more time for us to get caught up in something), and avoid busy Mondays and Fridays, as well as the day before and after holidays.

What makes the wait so long in the first place and what do we do to prevent long waits?

• Sick kids. Most of our “sick” appointments are fairly quick visits, and are scheduled as such. Children who are truly sick and require more time (breathing treatments, stitches, admission to the hospital, sending for x-ray, or watching as they sip fluids over a few hours) back us up. They take extra provider and nursing time and may tie up a room for several hours, limiting the available rooms for other patients. Please understand that this may happen any time, and even an otherwise low patient volume day can be consumed by one sick child. Most importantly, if it is your child, we will spend the required time to adequately treat him/her. If one provider is backed up, we will attempt to have another provider help out.

• “Oh, by the way…” This is a common phrase in any doctor’s office. When you have an appointment for one thing, but bring several concerns, the visit runs long. Scheduling experts recommend putting off all non-urgent and non-related things for future appointments, but we realize that families have limited days off to bring in their children. We try to help by addressing many of the concerns so you do not have to return. Sometimes it is not appropriate to tackle too many issues (none will be covered adequately if too many are attempted) and we will ask that you schedule another appointment. Things that go together, such as cold, cough and earache are easily addressed at one visit. It is not possible to discuss chronic headaches, warts, asthma, and other complaints when a simple "sore throat" appointment was scheduled. This also applies to the list of questions and concerns parents bring to well visits. A well visit is designed to address safety, growth, nutrition, development, and other specific topics. Saving up a year's worth of concerns to discuss at that one appointment is not wise. It does not allow time to devote to each issue appropriately. We ask that you come in for separate visits as needed and not wait to discuss everything at one visit.

• Siblings. Many times each day our providers are asked to “just take a look” at brother or sister. This innocent question seems to only take a few minutes, but these minutes add up by the end of the day. Since we will see all sick children on a same-day basis, please check in each child you want checked or discussed. If you just want to discuss another child without an appointment, call the nurse line or e-mail your provider through our web portal.

• Sometimes we joke that the bus just stopped by. There’s no one in the waiting room, then suddenly the waiting room is full of people. If someone's late to an appointment, someone else right on time, and someone early, then it gets backed up. Please be on time for appointments whenever possible and call if you will be more than a few minutes late. We understand that sometimes there is unexpected traffic or a child pukes during the drive, so we will always attempt to fit people in who missed their appointment time, but realize that it makes others wait. Do not schedule an appointment if you know you will be late. It’s amazing how often we hear, “It always takes so long to get from work to daycare and then to your office.” If it always happens, why not adjust your travel time to be at the office on time?

• We will see your sick child the same day during business hours. It is easy to pre-schedule well visits and follow up appointments, but it is difficult to anticipate how many kids will be sick on any given day. We track visit numbers by time of year, but there is variability. Our providers have more well visit openings in their schedules and fewer sick slots during the summer, but more sick visit openings and fewer well visit appointments during the winter. Call early in the day if you want to schedule with a particular provider. If a schedule is full, we do not "overbook" a provider. 

• Inappropriately scheduled appointments. It is difficult for our schedulers to know exactly how long an appointment will run, but they do attempt to schedule based on the concerns of the caller scheduling. For instance, a sick visit with ear ache, cough, or sore throat is typically well covered in 10-15 minutes, and is scheduled as such. If the child is actually wheezing and in need of breathing treatments, this becomes a long appointment where the provider will need to assess the child several times. Understandably the child needs this attention, but was not scheduled for a long visit, so other patients will end up waiting longer. Please attempt to be clear with your concerns when scheduling to allow proper time allotment for your appointment. 

• Insurance information and other “bookkeeping” issues. Please be ready with all current insurance information as you check in. If you have not filled in a Patient Information Sheet in the past 12 months, you will be asked to provide a new form. Filling this out at home is easier for most parents. You can print out and fill in our Patient Information Form ahead of time if you prefer. For all new patients and existing patients with insurance changes, our receptionists may need to call the insurance company to verify information, so please arrive 10-15 minutes early. Have your co pay ready. Again, it is amazing how many people have to run back to the car because they leave their wallet there. (Never a good idea, by the way... thieves love wallets in cars!)

• Physical forms. Often high school age kids come in for sport and camp physicals without the required form filled in. The form MUST be completed before the provider can sign it. Many of these forms are detailed and take time to fill out. Please fill out your forms before coming to the office. If you do not have a form, click here.

• Behavior. Some parents spend an extraordinary amount of time disciplining their children in our office. Often it is the sibling of the child with the appointment, not even the child being seen. We know that all children are rowdy sometimes, but it makes the visit long if we have to repeat what is said multiple times because the parent was distracted by the child, or if we have to wait for the parent to calm the child down. Bringing only the child(ren) with appointments helps this situation. If a child resists being weighed and measured, it takes the nurse longer to get him ready and the next patient might be ready before you, meaning you might end up waiting longer for the provider. If the child fights an exam (very common between 12 and 36 months) it takes longer to adequately evaluate the child and extends the provider time in the room, making the next patient wait longer. We expect and understand this, but it still adds time to our day, and if we have several of these children in a row, it slows us down. 

• Walk-ins. We offer an urgent care walk-in clinic daily. We staff this based on time of year and expected volume of patients. Obviously without scheduled appointments, this is at best an educated guess. Try arriving before the last 30 minutes of walk-in, as this is the busiest time. It usually has fairly short waiting times and you don't need to spend time calling to schedule then waiting for your appointment. (A benefit to our walk in clinic versus another clinic around town is that we have your child's records and the visit will be added to your child's permanent health record. We know you and your family. By seeing us, you help us keep current in your child's health.)

What can you do to help?

• Try to be on time. If you will be late, please call. Your appointment might only be set for 15 minutes, so arriving just 10 minutes late nearly misses it altogether. It is not possible to shorten the actual visit, so we will now run late for everyone else. We may ask people who are late to see another provider to lessen the disruption to others. 

• Arrive no more than 5 minutes early or warn the staff that you are early. People who arrive early are just as disruptive to a schedule as those who show late. Although you might luck out and show up early when someone else has called that they are running late, but it rarely works that way. Early patients take front office staff and nursing time away from people checking in on time, and may put people scheduled ahead of them back in line. Kids learn early in school "no cuts" and this is the same concept. We attempt to keep track of who is being seen and order them in order of appointments, but some patients show up early and then are upset at the "long" wait time and their kids are out of control in the room from boredom of the extra wait time. 

• Schedule your appointment appropriately. Scheduling for an earache when you really want to discuss the implications of your divorce on your child's behavior is not appropriate. An earache is a short appointment. Chronic conditions, behavior concerns, and well visits are long visits on the schedule.

• Be flexible. If the provider you scheduled with is very busy due to unexpected issues and you are offered to see another provider, please consider this option. If you want to see only the person you scheduled with, remember you will wait longer. If another provider has an opening, you will get more prompt (but still great!) care.

• Avoid scheduling during nap or meal times. Being tired, sick, and hungry makes kids more irritable, can prolong visits due to behavior problems, and makes the visit less valuable due to difficulty holding a conversation, answering questions, and staying on task. (Please avoid giving children snacks in the office. It can be a real problem for others with food allergies.)

• If you must leave by a specific time, let your nurse know. She might suggest seeing another provider if the one you are seeing is delayed.

• Bring only the child scheduled for an appointment if possible. This allows the focus to be on your child that is being seen, and not on the fighting and running around that happens with siblings. Also, there is less exposure to the germs in our office, so you don't make a trip back a few days later with a sick sibling!

• Schedule all children you wish to have seen or discuss.

• Have your insurance card and co payment ready at check in.

• Pre-fill out any forms needed: Camp and Sports forms and our Patient Information Sheet.

• Schedule early in the morning or afternoon - less time for us to get hung up with another patient.

• Bring books or toys (this is a great time for hand held electronics) for your child to stay occupied with during the wait to make it seem shorter for all!