Evolution of Illness

When kids are sick, parents understandably want them to feel better quickly. They want a sound night's sleep. They want to be able to return to work/school. They want to see a happy, healthy child again. They come to our office hoping for answers and a cure.

Sometimes there is no quick fix, just treating symptoms and time.

This is the season we are seeing a lot of sickness. It's been about 11 years, but I remember the frustrations of having a sick baby when my daughter had bronchiolitis. Some of the details are muddy, but I remember the feelings of inadequacy because I couldn't help her feel any better any faster. I knew the illness tends to get worse before it gets better and there is little we can do to alter its course, but knowing this it didn't make me feel any better as the mom who was helpless.

I lost sleep for several nights as I watched her pant (not breathe, but pant). I resorted to giving asthma-type breathing treatments (because my son had wheezing so we had everything we needed to give a treatment at home) despite the fact that they didn't seem to help her much. It was probably the humidified air that helped more than anything. But the vaporizer in her room and the saline to suction her nose wasn't helping, so I wanted to at least try the asthma medicine. She kept wheezing. We brought her in to the office 3 days in a row to have someone else check her. I can't check oxygen levels at home and needed someone to objectively examiner her.  So three days in a row we went in for repeat exams. She was able to maintain her oxygen level and stay hydrated despite breathing 60-70 times/minute for days. I still don't know how. I remember wishing her oxygen level would drop enough that we could hospitalize her, not critically, just enough. Then she'd be on monitors, and maybe I could sleep a bit knowing someone else was watching her. Thankfully she never got that sick, and eventually we were all sleeping again, but it took a long time for that.

So I understand the frustration when we tell parents things to do at home and ask that they come back in  __ days or if ___, ____, ___ symptoms worsen. It really isn't that we are holding out on a treatment that will fix the illness, it's just that we don't have a quick fix for many illnesses. We need to be able to examine at different points in the evolution of the illness to get a full picture of what is going on.

The exam can tell us a lot, but it doesn't predict the future. One minute ears can look normal, the next they develop signs of an infection. I cannot say how many times I've heard a parent complain that someone else "missed" something on exam that I now see. Yes, sometimes things can be missed, but I suspect that most of the times the exam has simply changed.

I learned this phenomenon as a resident on the inpatient unit. I had a patient who had been admitted for an abdominal issue. I did a physical on the child in the morning before rounds, including looking at ears, which were normal. Late that afternoon the nurse called because a fever had started. New symptom, so another exam was done. This time the ears were red and full of pus. Within hours this child had developed a double ear infection. I examined the ears both times and they were definitely different.

I understand the frustration (and expense) to take kids back in to be seen if symptoms worsen, change, or simply just don't resolve at home. If symptoms change, we need to re-evaluate, which includes an exam. Medical providers cannot look into the future to see what will develop. It is not appropriate (or effective) to put kids on an antibiotic or iv fluids to prevent the illness from taking its natural progression. Sometimes we need time to see how the illness progresses to see what other treatments might be needed.

When parents call back and want something else done, they are often upset that we want to see the child again. I hear many types of complaints.

Money is probably the biggest issue. It is not because we want your co pay. The "we" I use here is not just my office and I am not speaking of any particular situation. With online doctor rating sites, social media sites, and knowing doctors around the country, I write with many examples in mind. I've seen online complaints that doctors are just money hungry, trying to get someone to come back in just so we can charge more money. It is true that we charge for every visit. We are not able to waive the co pay because we did "something wrong" or "missed a diagnosis" the first time. Each is a separate visit with updated information and a separate exam. Insurance contracts dictate that a separate co pay is charged. We must adhere to legal contracts or it would be considered insurance fraud.

Increasing our numbers for "production" is sometimes brought up. It is not because we want to fill our waiting room with more children to increase the waiting time for everyone else. We don't want to waste your time or ours. But we need to see a child to know what is happening at that moment to be able to give any valuable advice and treatment.

We want to see your child again because we need to see your child to know what to do. Maybe now the child's symptoms have changed.  Maybe not, but without the history and exam we do not know. The exam might now show wheezing, low oxygen levels, a new ear infection or sounds of pneumonia. Sometimes the exam still is overall normal, but the fever's been going on long enough without any identifiable cause, which requires lab and/or xray evaluation. 

Please remember that if you get a different answer at a different visit, it doesn't mean that the first assessment was wrong. Usually it is due to a progression of the illness, and things change. Human bodies are not static.

Walk In Clinic Etiquette

Cold and flu season always brings more people to the doctor or health clinic.  The pure volume can be overwhelming for any clinic, scheduled or walk in, but the nature of walk in clinics makes the volume unpredictable.   Sometimes no one in walks in, other times several come at once.  Walk in clinics are wonderful for the overall rapidness at which one can be seen, but how can you help streamline the process?

1.  Write down symptoms.  It sounds crazy to write down things since you know your child better than anyone, but if your child is sick you are probably sleep deprived and might forget important details.  Writing things down helps everyone summarize what is going on and get facts straight.  Very often the diagnosis lies in the history, and if the person bringing the child in does not know symptoms well, it is difficult to make a proper diagnosis.

2.  Expect to be seen for one acute problem.  Illnesses typically have more than one symptom, but they are a single illness.  It is appropriate to bring a child in for multiple symptoms, such as cough, fever, and sore throat.  It is not appropriate to bring them in for those issues as well as a wart and headache of 3 months off and on.

The nature of walk in clinics is that they move rapidly.  The number of patients checking in at any given time can be large, so each visit must be quick.  If you need more time with a provider, schedule an appointment.

3.  Do not attempt to get care for a chronic issue.  Chronic issues are always best managed by your Primary Care Provider (PCP).  This does not include sudden changes to a condition, such as wheezing in an asthmatic.  Your child can go to the walk in for the wheezing, but should follow up with the PCP with a scheduled appointment to discuss any changes needed to the daily medication regimen (Action Plan) to prevent further wheezing.  This is especially important if you went to another urgent care or ER for initial treatment so that your doctor knows about the recent exacerbation of a chronic issue.

4.  Do not add additional children to the visit. Many parents bring additional kids to the visit and ask if we can "just take a peek" in their ears. If you want them seen, check them in too.  Again, walk in clinics move quickly and the "quick" peek takes longer because the child is running around the room or fighting the exam.  The quick peek also does not allow for documentation of findings in the medical record, which might be helpful in the future.

5.  Have your insurance card and copayment ready at check in.  Streamline checking in by having everything ready.  It is amazing to me how many people must return to their car for their wallet.

6.  Try to bring only the child who is being seen.  It is difficult to focus on one sick child when another is running around the room, falling off the exam table, or constantly asking questions.  This applies to scheduled as well as walk in visits.  I know this becomes a childcare issue, but it can really help focus on the child being seen.

7. Bring medications your child has recently taken.  Often parents have tried treatments at home, but are not sure what was in the bottle.  Bringing all medications (prescription and over the counter) and supplements helps us advise on correct dosage and use of the medications.

8.  Go to a walk in clinic at your regular doctor's office if available.  I know not all doctor's offices have walk in hours and most are not open all night long, but most walk in type visits are not emergent, they can wait until the next business day.  Treating symptoms with home remedies is quite acceptable for most illnesses for a couple days.  This might even be beneficial to improve the immune system's ability to fight illnesses and to see how the symptoms change over time. Some kids are brought in at the first sign of fever, and look normal on exam, only to develop cough and earache over the next few days. When the symptoms change, so might the exam and treatments!

The benefits to going to your regular doctor's office to see your PCP or another provider with access to your child's medical record are many.  The record has your child's immunization history,  previous drug reactions, any underlying illnesses or frequency of illnesses (as long as you use them exclusively), as well as any other pertinent information.  Primary Care Providers and their staff also know your family and that alone can help!

Some walk in centers limit services or ages of patients.  The provider at the clinic may or may not have adequate training in pediatrics, and they often do not have others around who can help if a problem arises that is out of their comfort zone.   If a baby is crying, the eardrum gets red, but isn't necessarily infected.  A provider without a lot of experience will often err on calling it an ear infection. Giving a prescription for an antibiotic makes parents happy, regardless if it is necessary.  Better satisfaction scores for the clinic.  Faster turn around time since it takes longer to explain how to treat a cold than it does to write a quick script.  Everyone's happy, but antibiotics are overused.   They also do not offer follow up of issues to see if there is improvement.  They do not take phone calls if there is a followup related question.  You must call your PCP, but if we haven't seen the child for the issue, we are unable to give appropriate advice. 

There are gaps in care even at urgent cares where there is a pediatrician or midlevel provider with extensive pediatric training (there is more than one option in this area).  They do not know your child's full medical background and do not update your child's health record in the medical home.  Following in one office allows us to see the chronicity or recurrence risk of an issue.  If your child goes multiple places for every sore throat, the PCP only sees him for well visits and no one recognizes that a tonsillectomy might be beneficial. 

9.  Please don't use walk in clinics to have health forms filled out.  I know it is tempting to get a quick physical just to have the sports form or work physical signed, but this breaks the concept of a medical home.  Your regular doctor doesn't get to see you for a comprehensive visit, reviewing growth, development, safety, immunization status, and more. We lose the opportunity to share what has happened in the past year and continue our relationship.   If the medical home does all the well visits and vaccines, we have up to date records and can update as needed.  Some kids have missed school because vaccines were missed and they can't return until they get them.  Others have gotten extra doses of vaccines because a record of a shot was missing and parents can't remember where they got the vaccine.  We request a well visit yearly (after age 2) within the medical home.  If in need of a well visit, please call the office to schedule! 

Middle Man Payment Plan?

Healthcare billing is a very complex issue, mostly because people are familiar with purchasing things with money or credit in full disclosure of costs, not the complex system of insurance billing.  


People pay a lot for insurance, and then expect insurance to cover the cost of care, but they often do not realize the details of their contracts with insurance - AKA the Middle Man.  

Patient <--> Insurance <--> Doctor Office

This is  a long post, so bear with me... it is such an important but complex issue. I am only touching the surface here.  If you can't read the whole thing, at least hit the highlights at the bottom!

Typical purchase:  Buying a shirt. 

• I select my favorite store. 
• I look through the rack of shirts and pick one that is the right size and color.
• I look at the price tag and decide if I want it.
• Maybe I have a coupon or it's on sale - I can calculate the discount!  
• If it is the right cost and meets my needs, I make the purchase. I can choose cash, check, credit card.  Maybe I have a gift card! 
• If it isn't right for any reason, I keep shopping.

Healthcare purchase: Full of Unknown costs... making the decision to "purchase the product" much more difficult.  

Product? What product?

• "Product" is the expertise and knowledge of the healthcare professionals. 
• There is nothing to take home to show.  
• Time spent with the provider may or may not end up with a prescription or other identifiable thing that shows what the money was used for.  
• You might leave the office with as many (or more) questions because final diagnosis of a problem can be a process that takes time.
• You might disagree with the diagnosis or treatment given.  You don't have the option to choose another shirt. You already bought this one when you signed in.  You could buy another (2nd opinion) but you'd have to pay for both.  I hope you talk about these concerns at your visit... don't just worry that we "missed" something or did it wrong! 

Costs are becoming more important to the consumer as many insurance companies are putting more financial responsibility on their policy holders and covering less medical costs.  So it would be best if we let you know our fees and your payment amount before we see your child, right?  Well, there's a catch to that.  

The catch?  I don't know what your insurance contract requires of you, so it is impossible to accurately tell you what your real cost will be until after my office gets the insurance adjustment.  I don't know exactly what the insurance company will pay and what they'll discount ... my billing staff can make an educated guess based on past experience with a company, but it varies from case to case.

In this difficult economic time this places financial stress on families. I understand this and am happy to work with families on payment plans if they let me know their hardships, but often they simply yell that I billed it wrong. Because of contracts between my  office and the insurance company and the patient and the insurance company, there are many rules and laws regarding how to bill and collect payment.  


Back to Healthcare "purchase":

• Patient/consumer uses a service.
• Place of business (ie doctor's office) submits a bill based on well defined codes.  This bill doesn't go to the patient.  It goes to the Middle Man.
• Middle Man (insurance company) reviews the bill submitted.  
• Middle Man discounts each item to what they believe is a reasonable fee.  
• Middle Man pays the part of the adjusted fee that they are contracted to pay. 
• Middle Man sends us this information and we write off the discount they applied and bill the patient/consumer the difference.  
• We have provided a service and it is several weeks to months before any money is collected. Anyone in business knows the consequences of this timeline of money collection. 
• Payment collected from the doctor's office depends more on what the insurance company adjusts the bill to rather than the original bill itself. 
• Note: although the bill comes from us and is due to us, it is a result of your insurance plan/contract!  In general, the less expensive your plan for monthly health insurance, the more you are responsible to pay with each use.

Let's run through a couple scenarios of this Middle Man payment plan.


First scenario: Well visit plus additional concerns. A child is scheduled for a well visit but woke with a fever and cough.  He has an insurance company that requires a copay for each issue seen in the office.  We provide the care for a complete well visit (monitoring growth, development, nutrition, safety, reviewing vaccinations, etc) and bill for that service. We also ask further questions regarding this illness and symptoms and discuss management for the fever and cough.  Addressing and Documenting these issues (after all, the kid isn't well) is important.  When the bill is submitted to the Middle Man, the insurance company sees that the child is sick, so tells us to bill the family for a 2nd copay.  Our contract with this insurance company requires this, so we must bill to the family.  By law we must follow our legal contract.  To fail to do this is insurance fraud.  I'm not willing to go to jail to save a family a few bucks.  Sorry. I love my patients and want to help, but I don't want to have to go to jail for trying to do a good deed.


Second scenario: Screenings and tests sometimes, but not always covered. Another child is in the office for a 3 year old well visit and is due for a vision screening.  We know that most people either don't have vision coverage or their insurance only covers one vision test every 1-2 years.  The standard of care (ie what should be done if we want to provide the BEST care) is to do the vision test at this age.  This causes many possible scenarios, most of which equates to a headache for pediatricians:

• If a patient passes a vision screen done at our office and the insurance pays:  great. Rare, but great.
• If a patient's parent refuses the vision screen in our office (or fails to take the child to the specialist when we refer) because they feel the eyes are normal and don't want to pay, but later learn there was a problem that should have been addressed earlier for better outcome: parent is upset with us that we didn't insist on screening. The child also suffers from an undiagnosed vision problem.  
• If a patient passes a vision screen and insurance applies the charge to the deductible: the parent is upset at us for charging something "that wasn't needed. I knew the eyes were fine." (Note: we are the bad guy because the bill comes from us, despite the fact that it is their insurance company that chooses this payment method.)
• If a patient fails our vision screen and insurance pays us: parent is upset because we used up the once/year (or every other year) coverage, and now they pay out of pocket for the ophthalmologist.
• If patient fails our vision screen and insurance doesn't pay: parent is VERY upset because they must pay twice! (us and ophthalmologist) Why is this? Screenings by nature pick up some normals so they don't miss any abnormals. If a child fails at our office, they need to be seen by a specialist to confirm if there is or is not a problem.  Two visits by two providers with two fees.  Ugh!  

So... how many of these vision screening scenarios ended up with all happy?  ONLY ONE RARE CASE!

Please read your policies and ask questions to your insurance company before visiting the doctor so you know your financial responsibility.  Plan accordingly to save some money for healthcare needs.

One major issue we are seeing is described in scenario #1 above.  We follow the use of CPT codes as published by the American Medical Association. To bill both a sick and well visit on the same date of service, we add a Modifier -25 to identify separate preventive medicine service (well child exam) and a problem-oriented service (ear infection, hurt foot, earwax removal, etc) on the same date of service. This is the national standard, but not all insurance companies cover it the same.  Middle Man may tell us to charge the insured family a second co pay.  Why?  Because they want their members to pay their contracted portion of each visit.  Simply saving up multiple issues to be seen on the same visit day does not result in a person being less responsible for their portion of medical costs agreed to in a contract.  You are responsible for what your contract states.


Or maybe you simply have a high deductible plan.  You will be responsible for payments until you reach the magic number in your contract.  You have the benefit of lower monthly premiums, but expect to pay more each time you need medical care.


Another issue is labs.  Some insurance companies ONLY pay for labs done at their contracted lab. This means that quick Strep throat test we did gets charged to you.  Unfortunately we didn't know this from your insurance card.  Is it worth it to you for the convenience of knowing results right away to pay for the rapid strep, or would you prefer to wait for the lab to give culture results in a couple days? If this is important to you, call your insurance company.  Tell us before we do the test!


Billing codes separate out parts of services/product. Immunizations are a great example of this. There is the vaccine component, and there is an administration cost to cover costs associated with a vaccine:

• vaccine insurance -- they are expensive and need to be covered!
• temperature control of the refrigerator--did you know if the temp gets too high or low it alarms so our vaccine doesn't become ineffective? After hours one of us is automatically paged and we have to go in to see what is wrong?
• incidental supplies like syringes, needles, bandaids-- all the little costs add up!

Some insurance companies pay only the vaccine component, but not the administration fee. It goes toward the deductible.  Do you know how your plan works?

What does this all mean?

• We would like to provide the best care to our patients in a timely and economical manner, but we need your help identifying what you want done and not done due to costs before your visit. 

• If we address well and "not well" issues on the same day, it might mean a 2nd co pay or deductible for you to pay.  Some issues deserve a separate visit due to the nature of the concern.  

• We encourage you to do the recommended follow up labs and tests discussed at visits for the best medical care of your child.

• If your insurance company tells us to write off a portion of your bill, we do.  It is illegal to balance bill a patient.

• If your insurance company tells us to bill you for a service, we do.  It is illegal to write this portion off.   

• If you have a high deductible plan, save the money you save on premiums monthly in a special account for use when needed. 

• If you have any questions about your bill, please feel free to call our billing department to discuss. Please choose nice words with our staff. They are only the messenger!