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Pecan Tree Pediatrics Explanation of Patient Costs
Pediatrics Tree Pediatrics is committed to providing high-quality care for the children in our community. Conversations that are related to billing and collecting money can be challenging, but it is important to know that we are an independent small business. Our business relies on ensuring that we are billing and collecting payments accurately and that we comply with our insurance contracts.
We strive to provide services that are fair and convenient to our patients. Many parts of your child’s care happen when we are not in the exam room.
For example:
- We provide health care phone communication for questions 24 hours per day.
- We process referrals for your child.
- We maintain and update your child’s medical and immunization records, and provide these to other health care professionals, schools, and daycares when requested.
- We complete health care forms including sports participation forms, daycare forms, therapy forms, home health forms, FMLA forms, and many different forms for school.
It takes many people to provide these services and adhere as much as we can to appointment times. To do this, we need to ensure our staffing numbers match our desire for comprehensive care, efficiency, and timeliness.
The following is a general guide to types of visits and payments to help you better understand what you are paying for. We advise that you consult your insurance company benefits and guidelines before making an appointment with us because we are contracted with many insurance companies. It is your responsibility to understand your specific insurance benefits. The following is information that we consider to be helpful.
What is a Co-pay?
This is a fixed amount you pay for health care services when you receive care.
Your health plan determines your co-pay for your visits. If your insurance plan requires co-pays, we collect the co-pay at the time of service, but it may be billed to you later if the type of visit changes based on what is done at the time of the visit. For example, if you have a Well Child Visit and additional E/M services are done such as for an ear infection, you may get a bill for your co-pay at a later date.
What is a Deductible?
This is the amount you owe for health care services before your health insurance plan begins to pay. For example, if your deductible is $1000.00, you must pay for any health care costs until that amount reaches $1000.00. After that, your insurance plan should pay costs in excess of $1000.00. Not all services are applied to your deductible.
Sometimes your deductible is a percentage of services. The deductible plan and amounts vary with insurance companies and the type of plan you have within an insurance company. It is important that you understand what is applied to a deductible and if you have met your deductible. Deductibles can be applied to E/M codes, procedures, and tests.
Encounter Visit:
This includes but is not limited to Sick Visits, Urgent Care Visits, Problem Visits, Chronic Medical conditions Follow up, Medication Visits, and Follow Up Visits.
Examples of Encounter Visits are office visits for a problem such as a fever, sore throat, or vomiting. It could also be for anxiety, depression, or behavioral issue. Other examples are visits to evaluate for concerns for ADHD or a visit to manage ADHD medication. Sometimes, we will have you follow up for an ear recheck or weight recheck – these visits are also Encounter Visits. Each visit will be billed as a separate visit and result in a new charge (also known as price or cost).
The charge of the visit is based on an Evaluation and Management (E/M) code that is determined by the symptoms, diagnoses, and type of information that is reviewed, the risk of the symptoms or diagnosis, and the plan. We are required to follow the coding guidelines and generate a code based on the guidelines. Based on the E/M Code, we are required to bill the insurance company and patient and collect from each responsible party accordingly. Failure to do so can result in consequences including fines and not being able to have a contract with certain insurance companies.
E/ M Codes do not include a review of preventative services or sports physical only visits. It also may not include the tests or procedures done at the visit. For example, if your child needs to have earwax removed to examine the ears, there will be a separate charge (or additional cost) for that or a strep test will have a separate charge that may require payment because your deductible may not be met.
These Encounter Visits are covered by almost all insurance companies. A Co-pay is charged and/or cost may be applied to the deductible.
Nurse Visit
This is a visit during which you will only see a nurse. Examples include the visits for immunizations only or only having blood work performed in our office. It does not include a discussion of a new problem or an evaluation from a doctor. If the doctor needs to come in to discuss any issues, it is no longer a nurse visit.
There will be a Nurse Visit Code. A co-pay may be required and/or costs for additional services may be applied to the deductible. For example, even though it is a Nurse Visit, there may be additional codes that lead to additional charges (or costs) to you.
Well Child Visit: Check-Up / Annual Physical / Wellness Exam
This is an office visit to monitor growth, and development, look for hidden diseases, give advice on common issues that affect that age group, discuss safety, and encourage healthy habits, healthy eating, and physical activity.
The charge (or cost) of these visits is based on a code determined by the patient’s age at the time of the visit. This charge will cover the interview and exam of the physician. It will often include the costs of all of the procedures and tests that are part of the wellness exam, but not all insurance provides coverage for all services. In some cases, the insurance company does not cover items such as vision or hearing screening, checking cholesterol, or some of the questionnaires that are important for us to evaluate health. This is important for you to understand for your specific insurance plan. We do not alter our plan for a wellness checkup based on an individual patient’s insurance plan.
The Well Child Visits are covered by most insurance companies without a co-pay.
The Well Child Visit Code and charge does NOT cover services that address new symptoms, sick symptoms, and changes to the management of chronic problems.
Why did I get charged a co-pay or deductible when I had a Well Child Visit?
Some questionnaires, procedures, or tests may not be covered under the Well Child Visit Code for some insurances. Additionally, if a patient has sick symptoms, additional problems, new medical issues are discussed, or changes in the management of chronic conditions occur, these are not covered under the Well Child Visit Code and additional services charges are applied as per the Evaluation and Management (E/M) coding guidelines.
An example is when you, your child, and your doctor discuss an acute illness (an example is an ear infection), new condition (an example is migraines), or manage a chronic illness (an example is ADHD) during a Well Child Visit. Medical decision-making for treatment involves more than simply writing a prescription; it involves our judgment, knowledge, and time. As such, the Well Child Visit Code and the E/M Code for the illness may be billed as two separate services for the same visit.
To help understand this, think of work on your car. If you bring your car in for a routine service, you pay for a certain list of services. If at the same service appointment, you ask your mechanic to evaluate and repair a certain knocking sound, you would be charged for that added service, even though it is the same appointment.
At Pecan Tree Pediatrics, we are careful about how we code and bill our medical services. We know and understand that health care is not the same as car repair – both in its importance to you and the way for which it is paid. Yet, we also understand that to maintain an office that meets all your needs, we must be mindful of costs and revenue.