By: Suzanne Berman, MD, FAAP & Angelo Peter Giardino, MD, PhD, FAAP
Parents are sometimes surprised when they get a bill from their pediatrician's office for part―or all―of their child's well visit. Sometimes parents are even concerned that their pediatrician has made an error in their bill.
While any billing office should be happy to review its records for errors, the following are common reasons you might receive a bill after a well-child visit:
Reason 1: Your child's insurance plan is not ACA-compliant.
While new group health plans and exchange plans are required to cover all parts of the well child visit with no cost sharing, many health insurance plans are exempt from the ACA and, as a result, this requirement. These include existing unchanged health plans from before the ACA became law ("grandfathered" plans), federal employee plans, government plans like Tricare or ChampVA, ERISA-based self-insured plans, and membership plans like faith-based cost-sharing services.
Reason 2: Your child's insurance plan is ACA-compliant, but you received some preventive services which are not part of the ACA-recommended list.
The list of services that ACA-compliant plans are expected to cover can be found at the US Preventive Services Task Force. For example, routine vaccines―not travel vaccines―are in the list of covered preventive services. If a child received a travel vaccine as part of a well-child visit, an ACA-compliant plan may not full cover the cost of the travel vaccine (even though it is a preventive service).
Reason 3. Your child's insurance plan is ACA-compliant, but you received some non-preventive services as part of the visit.
Examples might include lung function testing for asthma or evaluation of chronic headaches done at a well-child visit. While both of these services help promote wellness, neither are included in the definition of a standard well-child visit service and may result in an additional charge based on the rules of your insurance plan. Some families only want covered preventive services at a well child visit; other families appreciate that a pediatrician can provide all needed services at the same time so you don't have to come back for a separate visit. Ask your pediatrician's practice about its policy regarding providing sick and well child visit services on the same date.
Reason 4. Your child's insurance plan is ACA-compliant, but you received more frequent services than is typical.
This occurs when well-child visits are scheduled closer together than what the insurance company considers to be "annual." Some insurance companies pay for one well child visit per calendar year. This means a child might have a check-up in September one year and July the next. Other insurance companies have more stringent rules and say that at least 365 days must pass between well exams. If not, the second well visit will be denied by your insurance company, and you will be responsible for the charge. Be sure you understand your insurance company's definition of "annual" before scheduling the appointment.
Reason 5. You received ACA preventive services, but your insurance company does not recognize the billing code(s) your pediatrician use for that service.
For example, vision screening for children ages 3 to 5 is an ACA preventive service. In 2017, there are three codes that are commonly used to report vision screening in children: simple eyechart and two types of electronic instruments.
Some insurance plans recognize the eyechart code as an ACA code, but not the electronic instrument code. In that case, a family would have no cost-sharing responsibility for an eye chart, but they would if their child could not use an eye chart, and the pediatrician screened vision using an electronic instrument. Families might understandably ask the pediatrician's office to use the covered code―even if the pediatrician used the other method. However, it is a violation of insurance contracts and federal and state laws to knowingly report the wrong code.
Other insurance plans might permit all the vision screening codes as ACA preventive, but not accept them when billed by a pediatrician. The plan only pays for them when the family makes a separate trip to an eye doctor.
The American Academy of Pediatrics (AAP) is constantly working with insurance plans to educate them on pediatric-specific codes. Learn more about this here.
About Dr. Berman:
Suzanne Berman, MD, FAAP, is co-founder and managing partner of Plateau Pediatrics, the first NCQA-certified level 3 patient centered medical home in Tennessee. She serves the American Academy of Pediatrics (AAP) in a variety of roles―including the executive committee of the Section on Administration and Practice Management and the Committee on Child Health Financing. Dr. Berman frequently contributes to AAP projects and publications regarding medical home practice transformation, rural health, coding, data mining, and policymaking. She and her husband have three sons.
About Dr. Giardino:
Angelo P. Giardino, MD, PhD, MPH, is the Wilma T. Gibson Presidential Professor and Chair of the Department of Pediatrics at the University of Utah's School of Medicine and Chief Medical Officer at Intermountain Primary Children's Hospital in Salt Lake City, Utah. He holds subspecialty certifications in Pediatrics and Child Abuse Pediatrics from the American Board of Pediatrics. He is also a Certified Physician Executive (CPE) within the American Association for Physician Leadership. He completed the Patient Safety Certificate Program from the Quality Colloquium, is certified in medical quality (CMQ) as designated by the American Board of Medical Quality and is a Distinguished Fellow of the American College of Medical Quality. Within the American Academy of Pediatrics, Dr. Giardino is a member of the Committee on Child Health Financing, the Council on Child Abuse and Neglect, and the Council on Children with Disabilities.