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!

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. 

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!

Eye Exams for All Children!

I often find that when I tell parents to start taking their children to the eye care specialist, the advice is not followed. Even at the 3 year well visit when I suggest a free screening, so I know it isn't always about the cost. We are all busy. I get that. But our eyes are important, and many pediatric eye conditions have much better outcomes if addressed early.

I was excited to see an article, No Child Too Young for Eye Exam in Pediatric News, thinking posting it would help parents. But after reading it, it was a bit technical, and written for physicians. So I thought  I'd break it down and explain why eye checks by an eye care specialist is so much more than a vision screen at school or the doctor's office. (I have stopped recommending vision screenings in my office - though they are still offered- because if insurance limits to only one screen per year, I want it done by someone who looks at the entire eye. See the second scenario in Middle Man Payment Plan for more.)

First, what do I mean by seeing an eye care specialist? Eye care specialists include Ophthalmologists and Optometrists. Ophthalmologists are physicians who went to medical school to obtain an MD (Medical Degree) or DO (Doctor of Osteopathy) degree and then did their residency in opthalmology. They can do eye exams as well as treat problems medically or surgically.  Optometrists go to school specifically to diagnose and treat eye conditions. Their degree is OD (Optometry Degree). They focus on routine eye care and vision correction. Both of these specialists can have specific areas of expertise and may or may not treat kids, so always be sure they have experience with kids the ages of your children.

In the article referenced above, Dr Sherry Boschert discusses myths of eye problems in children. These myths:

1. My child is too young for an eye exam. Not true. Ophthalmologists are routinely consulted in the Newborn ICU to see newborns for various eye concerns. Thankfully they don't have to be able to tell if view #1 or #2 looks better... even at my age, this is very difficult! Eye doctors can be specially trained to evaluate a newborn's eyes adequately.

2. Tearing must be due to a blocked tear duct. Many infants have blocked tear ducts, which causes the eye to water often. Since it is so common, it is most likely that your child with a tearing eye has a blocked tear duct. But... if it comes with pain or light sensitivity there might be more going on like a scratch on the eyeball or increased pressure within the eye.

What is a blocked tear duct? Just as it sounds, the tube that drains tears from the eyes into your nose become blocked. Tears are made in glands in the eyelid, cross the eye to moisturize it, then drain into the nose. With the drainage tube blocked, tears well up in the eye and it looks like the eye is crying. Usually this self-resolves by about 9 months of age, and parents can help by massing the area of the tube several times/day. It can lead to matting and drainage from the eye, but without redness or pain does not require any other treatment the first 9 months of life.  If it persists longer or if it leads to a discolored swelling below the eye we refer to an ophthalmologist (eye surgeon) for treatment.

Corneal abrasion is the medical term for scratch on the eyeball. How does this happen? Babies keep their hands near their face often and can get a fingernail in the eye accidentally. Often parents do not know what happened, but baby suddenly cries uncontrollably and won't open the eye. Older kids might be able to tell you that something went in their eye or they simply complain their eye hurts. They might have one area of redness (as opposed to pink eye where the entire eyeball is red). These scratches can be seen in our office with the help of special dye and a black light (Kids think this is pretty cool!) and are treated with antibiotic eye drops and close follow up. Severe trauma should be seen by an ophthalmologist. 

Glaucoma is not common in babies and children, but it is something that needs to be treated emergently by a pediatric eye surgeon (ophthalmologist). These babies appear to have beautiful big eyes, but they are caused by increased pressure within the eye. This pressure must be released to avoid permanent vision damage and treat the associated pain.  

3. All red eyes are contagious. Red eyes can be from viruses and bacteria (the reason schools/daycares kick kids out at the first sign of a red and/or goopey eye), but they can really be from many causes:

• viral conjunctivitis = pink eye from a virus. This is typically red and watery, but no mucus discharge. It usually comes with other typical "cold" symptoms. It is contagious, but like all viruses, no antibiotics help. 
• bacterial conjunctivitis = pink eye from a bacteria. These eyes are red with yellow discharge. Antibiotic eye drops do help contain this from spreading as well as treat the infection.
• allergic conjunctivitis = pink eye from allergies - typically itchy and watery, sometimes red eyes and sometimes a very thin mucus discharge occurs. A careful look at the inner eyelids will show small bumps. These can be treated with typical oral allergy medications or eye drops for allergies (available OTC). Eye doctors will use steroid eye drops for very bad cases, but these should be used with the direction of eye specialists who can check eye pressures to follow potential side effects.
• other illnesses - I commonly see reddened eyes with "sick" kids (Strep throat, upper respiratory infections, etc) who don't meet criteria for a true conjunctivitis.
• irritants - shampoo, smoke, chlorine, or other things entering the eye can irritate it and cause it to temporarily look red. Many of these require a flush of the eye. If pain or redness persists, they eye should be completely evaluated to be sure there is no damage to the eye surface.
• foreign bodies in the eye - sand, eyelashes, and other objects can irritate the eye. If unable to remove them safely at home, the primary care provider can help. If pain persists after removal or if they eye remains red more than 6-8 hours after removal, the PCP should evaluate for infection or abrasion.
• stye - These are bumps in the eyelid, near the eyelashes. If they are deeper within the lid they are called chalazions. They don't usually cause the eye to look red (except the bump itself) but I include it here because I see many kids for "pink eye" diagnosed at daycare, that have no pink eye, just a stye. These can be helped with a warm compresses. I do not feel these need antibiotics or eye drops but the author mentions those as a treatment option. If they grow large enough to cover the pupil or if they last longer than 3 months, an ophthalmologist might need to remove them.
• tired kids often have red eyes, usually parents notice this pattern
• injury - see corneal abrasion above
• sunburn - yes, the eyes can suffer sun damage just like your skin. Wearing sunglasses with UVA and UVB protection and wide-rimmed hats can help prevent this (as well as cataracts, macular degeneration, and other issues). If blistering or severe pain, these should be evaluated by an optometrist or ophthalmologist.
• hemorrhage = bleeding within the eye. This can be common after birth or with coughing or vomiting due to sudden increased pressure within the eye. They self resolve. 
• episcleritis = inflammation of part of the eye covering. The white of the eye can look pink or purple, the eye hurts and is sensitive to light, and it may tear. It typically self-resolves, but an eye specialist can help with the diagnosis.
• pinguecula and pterygium = small growths on the surface of the eye from various causes. An eye specialist can help with diagnosis and management, though typically no treatment is needed.

4. Children outgrow crossed eyes. Many children appear to have crossed eyes due to a wide nasal bridge, and they do "outgrow" this as their face shape matures. This is called pseudostrabismus and is not a problem with the eye.  It can be demonstrated in the photo at the top of this page. The right eye appears to cross in, but if you note the light reflex on the pupils, it is in the same location on both eyes. Truly crossed eyes would show the light reflex on different parts of the eye. This is caused from vision problems, eye muscle problems, or even in rare cases brain masses, and none of those go away without proper treatment. Your child's primary care provider can help determine if it is a "real" eye crossing or "pseudo" eye crossing, but an eye specialist can do a more thorough exam and determine treatment and follow up requirements. If you have pictures that show your child's eyes crossing, bring them to your appointment.

5. A bump on the eye will go away. See also "stye," "pinguecula,"and "pterygium" above. In addition to sties and chalazia, hemangiomas (collections of blood vessels), lymphangiomas (collections of lymph tissues) and dermoids (cysts) can cause masses around the eye. These should be followed by a pediatric ophthalmologist. Rhabdomyosarcomas are cancerous tumors that also require immediate treatment.

6. One eye is bigger, but it's a family trait.  An eye specialist should always evaluate the eye urgently if one seems bigger than the other. There are many causes, and many need emergent or urgent treatment.

7. Glasses worsen a child's prescription.  I have heard this often from parents, worried that the glasses prescribed to their child will worsen the vision over time. This is not only incorrect thinking, but opposite of what sometimes happens. Children's eyes and nerves are developing, and early vision correction will often improve vision over time. And they can see better to avoid injury, learn better, and in general see the world better!

8. Abnormal light reflexes are just a bad picture.  When a child's "red eye" looks more white, it can be simply the angle of the lighting or the child's eye pigments, but it can be a signal of eye tumor, cataracts, or abnormal eye shape (which leads to vision problems). Never ignore this! If your child's eyes don't look right in a picture, bring the picture to an appointment with an eye care specialist.

9. Different colored eyes are cute. This can be normal, but if eyes are a different color (either left vs right or colored stripes or rings within the same eye as in the picture) a vision check by an eye specialist is a good idea.

photo source: http://en.wikipedia.org/wiki/File:Heterochromia_Blue_Orange.png

10. Parents don't know best. What an obvious myth!

Vaccine timing... is it too late?

It is common in the summer months for parents to worry about their child's vaccines being delayed by summer travel or simply scheduling conflicts.

The typical question I am asked is along the lines of, "He is due for his 4 month shots on July 5th, but we are on vacation. Is it okay to wait until the end of July?"

or

"Tweeny is getting her first HPV vaccine today, but she has a big out of town tournament the week she is due for the 2nd dose. Can she come later?"

The answer to both questions: yes.

Vaccines are recommended with minimal intervals (you can't give them too soon) but if there is a delay for whatever reason (missed appointments, scheduling conflicts, immune compromise-such as cancer in a child or their caregiver) it is recommended to catch up as soon as possible.  Doses do not need to be repeated if the interval has been longer than recommended.

Conversely, it is not appropriate in most cases to give vaccines at shorter intervals or before the recommended age.

The 12-15 month vaccines are occasionally given before the 1st birthday, which does not count in Kansas.  Some states have a leeway for giving doses early, but Kansas does not. This is an issue with some children moving to our state from a more lenient state. Maybe they get their MMR a couple days before their first birthday. Does this protect them against measles, mumps, and rubella? Probably. Does the school count it? No. They need to repeat it.

Another scenario is children traveling outside the US. It is recommended for international travelers over 6 months to get an MMR early due to worldwide outbreaks. This dose does not count toward the 2 doses typically given because younger children do not make immunity as reliably, but is felt to potentially benefit those at higher risk due to travel.

Another common scenario involves Hepatitis A and B vaccines due to the ages given and the intervals required.

The dosing interval for Hepatitis A is a minimum of 6 months. We typically give it at 12 months and 18 months, but if these appointments are scheduled with less than 6 months between, we typically wait until the 24 month visit to do the 2nd Hepatitis A vaccine. This delay is okay. 

Hepatitis B vaccine is given in 3 doses, with the second 4 weeks after the first, then the 3rd at least 8 weeks from the 2nd and 16 weeks after the 1st.  If a newborn does not get the first Hepatitis B vaccine on the date of birth for whatever reason (too ill, parental preference, prematurity) and the one month well check is less than 28 days from the first dose, we delay the 2nd Hepatitis B vaccine until a future visit. This will push the 3rd dose back in most cases.

Each year the CDC updates the recommended vaccine schedule. We know it is confusing to parents, but we will help keep your kids on track!

When To See Your PCP?

We have many kids who come in for what I consider "band aid" medicine. We only see them when they have a problem. They never come in when well so we can know more about them: what they enjoy doing, what good (and bad) habits they have, if they are growing properly... you get the idea.

I understand that it is time and money to visit the doctor's office, but it is time and money well spent.  Sometimes it isn't obvious that this is an investment that benefits in the long run, but preventative care has been shown to be worthwhile!  I typically feel that I give inferior care to kids I rarely see because I only see them when they are sick, and can only focus on the current problem, not the overall health. You can't use a band aid to fix a broken bone or high cholesterol.  Without proper evaluation, you don't even know you have some health problems.  Even our cars get better care: people do routine maintenance checks on their car every 3-5 thousand miles, they don't just call the service station when it won't start.

Many problems have few or no signs or symptoms until they become severe. Anemia, elevated lead levels, high blood pressure, growth problems, and behavior concerns are some that we typically only see when critical if kids don't come in for recommended visits or do recommended testing.  Some parents fail to bring kids to the lab or other facility for recommended evaluations. This can delay diagnosis and puts kids at risk.

There are kids who visit urgent cares often, yet never come in for routine care.  It may be years between visits with the primary care provider (PCP).  "PCP" is used broadly here, since the primary care isn't done.  I understand that sometimes it is because kids wake in the middle of the night and the parent wants a quick fix, parents don't want to take off work so go on weekends, or the drugstore with a clinic is on the way home, but this isn't good care on many levels.

I don't always trust an outsider's assessment of certain physical signs.  Studies show parents are much happier with a diagnosis of "ear infection" and a prescription than an accurate assessment of a viral respiratory infection and instructions on home remedies.  Many ear infections are over diagnosed, leading to inappropriate antibiotic use, despite better parental satisfaction.  It benefits a practitioner who will be evaluated with patient/parent surveys to provide a prescription rather than an accurate assessment and instructions.  It also takes less time to write a quick script than to discuss the diagnosis, when to follow up if worsening, what to do to help symptoms, etc. Less work and more satisfaction, sounds good, but...

I don't know if the provider has enough experience with infants/young children to recognize what is really going on. I'm sure some of the people working urgent cares are really good at what they do, but many have little experience when they start working without supervision. They have no one to ask for a second opinion, so even after years of working they haven't developed the same skills as a practitioner working with more experienced providers who are able to help when needed.  Bad habits can be reinforced because they simply have no way to learn better skills.

Quick treatment of some infections that really do need treatment leads to poor immune memory, increasing the reinfection rate.  Strep throat recurrences have been shown to happen more when kids start treatment with less than 2 days of symptoms. There is benefit to waiting!  Strep should be treated within a week to prevent complications, but allowing the body a couple days to fight it off first builds the immune system!  It is okay to wait until office hours for many (if not most) problems. 

Difficulty breathing, dehydration, altered mental status, many injuries, and other things do require emergent care. If your parent alert system is telling you your child needs to be seen, then an ER visit is appropriate.

Keeping a good timeline of infections helps the PCP know when it is time for more intervention, such as ear tubes or prevention medications. If quick fixes are always at another location, we might not recognize the frequency. Even when parents bring kids in with a history of frequent infections we can't make appropriate recommendations because we might not trust the diagnoses.  Parents might not ever be told that their child has asthma that needs a prevention medication, so they simply keep using the quick relief inhaler, which puts the child at risk for serious complications.  Asthmatics who have regularly scheduled asthma visits when they feel well have fewer wheezing episodes requiring emergent visits and admissions.  Improve management of frequent or chronic illnesses by visiting with the primary care provider for illnesses and when your child feels well to optimize medication use, make appropriate referrals, improve safety, and spend overall less time and money.

Recommended routine maintenance is spelled out clearly in a book that comes with every car, yet a maintenance book doesn't come with kids. Yearly exams for those over 3 years (more for infants and toddlers) are recommended at a minimum.  Routine care also means regular visits to check on chronic conditions, such as asthma or obesity.

Preventative Care Guidelines are developed by people smarter than me by reviewing statistics including risk/benefit ratios, cost analysis, and more.  These aren't perfect and are regularly reviewed and often change. Some recommendations are simply not followed because insurance companies don't cover the cost. Pediatricians and many others are fighting for better coverage.  Examples of things recommended at various visits (depending on age):

• height/weight measurements

• blood pressure screenings

• lab screenings (anemia, lead, cholesterol)

• vision and hearing screenings

• development assessments

• mental health screens

• more...    

I'd like to think that I can make a difference with healthy lifestyles by providing regular routine care. Sleep habits, screen time, exercise, safety, and more are discussed at various well visits. This might uncover issues that need additional visits to be properly addressed, but early recognition helps improve outcomes.

I know my own kids take what others at the office (other doctors, the midlevels, even the nurses) say about safety, nutrition, and sleep more seriously than when I say it. (Never mind that I have qualifications to discuss and advise on this topic, I am just Mom to my kids!)  I also recognize that I see my kids daily, but don't know their growth parameters, blood pressure, heart sounds, etc from day to day living.  I bring my own children in for routine well care and follow up of health issues so that they can be the healthiest they can be.  It has become routine for me to schedule their summer physicals every Spring Break.  This routine helps because:

• it gives plenty of time to find a time/date that fits our busy family calendar and the provider's schedule. 
• it is a routine, which helps me remember... yes, I forget to make appointments just like everyone else! (Others use birth dates to remember, but I prefer summer visits for many reasons.)

It is not uncommon to uncover a problem during a well visit that needs to be addressed more completely but wasn't recognized ... even by smart, educated, attentive parents.  Please join me in healthy parenting and schedule routine checks for your kids!  Do the tests, treatments, and follow up recommended by your provider or speak up during your visit if you don't plan on doing them, which allows for open discussion about why they should or should not be done.

Use band aides when appropriate, but treat overall health with routine visits!

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!