What I Wish Parents Knew About Medical Billing

This post was originally featured on the Survivor Pediatrics Blog

One of the things that I do a lot here at our practice is talk to parents about their health insurance coverage. The conversation is usually about why they have a balance on their child’s account.

Health insurance is very complicated. At our practice, we deal with health insurance all the time and even for us, it gets to be very complicated sometimes.

Today, I had a conversation with a patient’s parent regarding medical billing issues. After explaining some in-and-outs about why we do certain things, the parent mentioned she had no idea things were the way they were and now understands why doctors’ offices have to do what they have to do.

She also mentioned that we should do something to spread the word. She said, “I think it is important for other parents to know this. Otherwise, how are things going to get better?”

I thought her idea to spread the word was very good. Therefore, I decided to summarize our conversation in an effort to help other parents understand, at the very least, a portion of medical health insurance.

CODING — A LOT OF WHAT DOCTORS DO

At a restaurant, generally you’ll get an itemized check that shows all the things you’ve ordered. Doctors do the same thing, but they do it in the medical chart.

Virtually every doctor who accepts health insurance uses codes (called CPTcodes) that are assigned to every task they and their staff performs. Everything from a simple blood draw, to immunizations, to the ear check, to specimen handling — all these things are “coded” separately.

WHY DO DOCS DO IT THIS WAY?

These codes are used by the patient’s health insurance company to determine the payment amount that the doctor will receive for his or her services. In other words, the health insurance company (the one actually paying for the services) wants to see what was done during a patient’s appointment. Hence, everything the doctor and the staff does has a code.

For example, if you are coming in for a child’s well visit, the pediatrician will submit a “claim” to the insurance company using the following codes:

• Established Well Visit – 99392
• Developmental Testing – 96110
• Hemoglobin – 85018
• Finger/heel/ear stick – 36416
• Lead Testing -83655
• Hearing Screen – 92587

If the child gets immunizations, those have codes too.

• DTAP-IPV – 90696
• Flu – 90660

Vaccine administration also uses a distinct set of codes. To further complicate things, some vaccines have a single administration code used with them, and others have multiple administration codes for a single vaccine.

• Admin – 90460
• Admin – 90461

OH, BY THE WAY…

Let’s say while you are in the examining room, you ask the doctor, “Ya know doc, little Lisa here has been pulling on her ear lately… she may have an ear infection. Can you check that for me really quick?”

This question requires the doc to perform an entirely different assessment than the well visit the child was getting.

The doctor, in order to show the insurance company that she did a completely different assessment, codes the ear pain diagnosis and adds a 99213 – which is an evaluation and management code that documents in the chart and on the claim to the insurance company that the doctor also checked the patient’s ear.

BUT WE FEEL LIKE WE ARE BEING SQUEEZED FOR EVERY PENNY

Parents often think when they are looking at the bill that the doctor is nickel-and-diming parents, when in reality, it is the insurance company that requires the doc to show their work in this matter.

The health insurance company doesn’t accept the doctor telling them, “I did a well visit — pay me our agreed-upon fee.” They want to know all the things the doctor did during a patient’s visit so they can decide how much they ought to pay the doctor for his/her services.

Since most patients (or in the pediatrician’s case, parents) don’t pay the doctors directly, but rather the health insurance company, they want to know what took place during the visit so they know how much they ought to pay the doctor.

It is the same as going to the restaurant and getting billed for all the side and extra orders. Although the main meal is accompanied by other things, like french fries or a salad, refills, side orders, substitutions and additions to the order are billed as extra.

Health care services are a la carte as well. 

WHY THEN DO PATIENTS HAVE BALANCES IF INSURANCE OUGHT TO HAVE PAID?

The insurance policy that a patient has chosen may not pay for all the services the doctor performed. So when the doc’s billing staff submits a claim for a visit, the health insurance company often comes back and says, “We are not responsible for these codes/services; these are the member’s responsibility per the member’s health insurance policy. ”

For example, the health insurance company may say, the policy your patient chose pays for a vision screen, but not for a hearing screen. Or they may say, we cover the well visit code, but not the ear ache code at the same time as the wellness visit.

DOCTORS GET STUCK WITH THE BILL

The doctor, already having performed services, now has to go to the patient and say, “Hey, remember that school physical I performed and you asked me about little Lisa’s earache? Well, your insurance says that the policy you have doesn’t cover the earache part, so I’d like to be paid for the work I perform in assessing your child’s earache.”

Of course, doctors don’t actually say that, but when a parent gets a bill for the earache, that is in essence what the doc is trying to say to the parent. And if one looks carefully at the  explanation of benefits (that document that the insurance company sends after they process a patient’s claim) one will notice they give an explanation as to why they are not going to pay the doctor for the service.

FUNNY HOW THINGS WORK

Here is an interesting, but crazy fact. In many cases, had the doctor deferred the earache question and told the mom to make another appointment to address that issue during another appointment, the health insurance company would have most likely paid for the office visit.

However, had the doctor done that, the patient would have most likely gotten upset at the doctor.

By treating the earache question during the wellness visit, the doctor runs the risk of not being paid despite doing the work. On the other hand, not addressing the ear ache, the doc runs the risk of upsetting the parent, who will probably think the doc is trying to squeeze another $30 copayment, which is clearly not the case.

CUTTING COST — NOT ALWAYS A GOOD IDEA

One of the major problems with this is that patients don’t understand what they are financially responsible for. Or, it’s often the case where patients don’t understand what type of health insurance they’ve purchased.

Just like with anything else, you get what you pay for. But patients overlook this issue when purchasing health insurance. They usually look at the monthly premiums and choose the lowest one. But by doing that, they are often reducing the amount of coverage, which means patients will get stuck with larger portions of their medical bills.

GROWING TREND TO SAVE COST

The health insurance company, in an effort to keep their premiums low, have shifted the cost to customers and their doctors. While in the past health insurance companies may have covered 100%, now they are reducing the monthly premiums but only covering 70% of one’s medical expense. Hence allthe high deductible plans out there.

WHY WASN’T I TOLD THEY INSURANCE DOESN’T COVER?

In our practice – which is a small three-provider practice – we see on average 60 to 75 patients daily.

Add to that there are virtually thousands and thousands of different health plans. In fact, we have patients whose parents work for the same company, but because they are at different pay grades, have different insurance plans.

The answer is, we don’t have enough manpower or time to sit on the phone verifying every single patient’s healthcare coverage. I know of practices that do, and God bless them. But as a practice we believe it is the patient’s responsibility to find out what is covered and what is not covered. The more time we spend on the phone with a patient’s insurance company, the less time we are able to spend providing health care for our patients.

MOREOVER…

As a practice, we consider that treating patients based on what the insurance covers and what it doesn’t, instead of treating by what the patient actually needs, is an unethical way to practice medicine.

Although most doctors that I know will take into consideration health insurance stipulations, they will not compromise a child’s health as a result of health insurance restriction and cheap health insurance coverage plans.

I hope this post will give all that read it some insight and perspective on medical billing. If you have a question, or don’t understand why doctors’ office do medical billing, feel free to leave a comment and we will try to address it.

Oh, and thanks for reading…

Brandon Betancourt is a practice administrator for Salud Pediatrics. You can follow him on Twitter  @pediatricinc

Is This Doctor a Good Match? What Questions Should I Ask?

Deciding on which doctor to take your child can be difficult. As a parent, you really don't know anything about the doctor or the office.

That is why getting referrals from friends and family is such a great option.But sometimes, it isn't enough. You may have different points of views, or a different situation - clinical or otherwise - which may require you to think differently than those friends and family. Also, children have different needs, thus you may require a different level of service than other parents.

We've put together a series of questions that we think may help you understand your doctor's office better. But more importantly, we believe that this small list is a great way to help you make the first step in determining if the doctor you are researching is the best match for you and your children.

• What are the doctor's present hospital appointments?
• If it becomes necessary for your youngster to be hospitalized, where would she be admitted?
• Is the practice easily accessible by public transportation?
• What are the office hours?
• Do you have evening or weekend hours?
• What is the doctor's policy on taking and returning phone calls?
• What is your policy on vaccines?
• Is there a nurse in the office who can answer routine questions?
• Is the doctor in a group practice with other physicians?
• Does another physician cover for the doctor at times?
• Who handles phone calls when the office is closed?
• How are visits for acute illnesses handled?
• Can I make an appointment on short notice if my child needs to see the pediatrician because of a sore throat or an infection, for example?
• What are the doctor's fees for sick visits, routine examinations, and immunizations?
• In what managed-care programs does the doctor participate?
• If your child should ever develop a complex illness that necessitates the care of one or more specialists, will your pediatrician coordinate care among all the doctors providing treatment?
• I’m expecting my first child, what do I need to do if I want to come to your office?
• Once I deliver my baby, what then?
• If I would like to transfer to Salud Pediatrics, what do I need to do?

If you would like to get the answers to these questions about our practice, click on this link.  Otherwise, feel free to print this list up and use it during your next appointment with your new doctor.

Why Eating Healthy Meals With your Kids is a Win for Everyone

Today's post is from guest blogger Dr. Nelson Branco. Dr. Branco is a practicing pediatrician in the San Francisco Bay Area and is very active with the local chapter of the AAP.

Dr. Branco is a frequent contributor to the Survivor Pediatrics Blog.

In this post, he addresses the question, what is the most important thing I can do to make sure my child is as healthy as possible?

Here is what he had to say: 

No pediatrician can answer the question: “What’s the most important thing I can do to keep my child healthy?” without listing three of four things.

I’m no different, but right now family dinners are at the top of my list. You could argue that immunizations, car seats, bike helmets, 9-1-1, sleep, or good hand washing are just as important, and I won’t disagree.

But it’s hard to overlook the overwhelming research on the positive effects of family dinners on children’s diet, social development, and sense of connection with their parents and siblings.

Family dinner means sitting down to eat with an adult, without any distracting screens, on most days of the week. It also means everyone eating the same meal. With our busy lives and over-scheduled kids, this can be difficult but not impossible. Even if you can’t do it every night, it’s worth rearranging the schedule so that some nights everyone can eat together.

Benefits of the family dinner vary depending on the ages of your children. For the toddler and preschooler, the family dinner will be short. Most toddlers will sit at the table for just a few minutes before getting distracted and wanting to run off and play.

The importance of the family dinner for them is modeling good eating habits and improving their diet. Children who are fed a separate meal will eat from the “Kids Menu” more often. This usually means hot dogs, pasta, chicken nuggets, macaroni and cheese and other foods that they are quick and easy to prepare, and don’t challenge their taste buds too much.

When you serve a meal for the entire family, the toddler is forced to watch you eat all sorts of different foods. (Assuming that your diet is better than the “Kids Menu” choices.) Colorful things – green, yellow, red, and sometimes even blue. 

Lots of textures and tastes, and more variety than they would choose on their own. This isn’t going to be immediately popular unless you have an adventurous eater. But over time, even the pickiest eaters will try new and different foods – after watching you eat them 100 or 1000 times.

For the school-aged child, family dinners are a time to share and talk. This is where they practice telling you about school, their friends, the picture they drew that day, the insect they found in the backyard or what books they are reading.

This is a time to practice manners – I can guarantee that you will have at least one conversation about the appropriateness of potty talk at the dinner table, and if say it enough times, they may start to use a napkin to wipe their mouth instead of a sleeve.

Many families have a regular way of sharing the day’s experiences:

“What was the best and worst thing that happened today?,”

“Highs and Lows,” or “What are you thankful for?”

The family dinner provides opportunities for assigning chores and responsibilities. Kids should learn that being part of the family means sharing the work as well. Setting the table, pouring drinks, clearing plates and washing and putting away the dishes are all things they can do to help.

If your child is interested, they can even take part in planning meals, shopping and cooking. For the very picky eater, helping cook can get them interested in foods they would otherwise never think about eating.

As kids get older, family dinners are even more important. Teens are going through a developmental stage where they are separating from their parents and joining a peer group.

Keeping tabs on them while they make this transition is important, and family meals give you a regular time to sit and talk about what’s up. If family dinners are a regular occurrence, you’ll notice when something is bothering your teen.

Take the time to sit down and eat with your kids, even if it’s not convenient. It doesn’t have to be every night, and it doesn’t have to be both parents. Eating healthy meals with your kids is a win for everyone.

To read more of Dr. Branco's post, check out his post on the Survivor Pediatrics blog by visiting: http://survivorpediatrics.wordpress.com/

Day Care Anxieties, You Are Not Alone

The process of choosing child care for your children can create a distasteful anticipation. I know it was not a pleasant experience for me. The thought of leaving my baby with someone else was dreadful.

I was still in my 2^nd year of my pediatric residency, so I didn’t have the option to stay with my baby. Despite my anxieties, I went through with it and the experience was great. 

According to kidshealth.org, about 70% of parents place their young children in some type of daily care. So you are not alone. With careful planning and preparation, this overwhelming, yet necessary task can be less stressful.  

It is important to consider specific guidelines that will help you find quality, professional care for your child or baby. For example, identifying your child’s likes and dislikes, temperament, behavior etc. will enable you to find a more compatible caregiver.

Other qualities one should consider in a caregiver or day care is experience, religious background, discipline beliefs and flexibility. In addition, before choosing a care setting, you should be aware of the options available and think about cost, location, and reputation.

There is a wide range of day care options to think carefully about. Nonmaternal care can range from large day-care centers to in-home family care to care provided by a nanny or a relative.

Types of Nonparental Child Care: Pros & Cons

CHILD CARE CENTER

Potential Pros

• Training & supervision of staff
• Resources and equipment
• Care is available during staff absence
• More likely to be licensed and subject to state regulation

Potential Cons

• Larger groups of children
• Greater staff turnover
• Staff background can vary greatly
• Higher cost
• Increased exposure to common illnesses
• Strict policy on caring for sick children

FAMILY DAY CARE 

Potential Pros

• Smaller number of children than larger centers
• Home atmosphere
• Possibility of more flexible scheduling
• Children of different ages
• Less expensive than some centers

Potential Cons

• Many family day-care providers are unlicensed and unregulated
• Supervision and background checks are often up to parent
• Resources and equipment can vary, depending on what is available

BABY-SITTER, NANNY OR AU PAIR

Potential Pros

• One-on-one care
• Care can be provided in infant’s or child’s home
• Possibility of flexible scheduling
• Possibility of care when infant is ill

Potential Cons

• Tends to be the most expensive type of care
• Burden of background checks and ongoing supervision is on parent

Studies have shown that the type of care children receive can affect a child’s social, emotional and cognitive development.

So what are the signs parents must look for to ensure that your child is safe and happy in a child care environment that is fun, educational, and nurturing?  

1. Caregiver to infant or baby ratio must be adequate. For example, in a room with 4 children aged 13 to 30 months, there should be 1 trained caregiver. In a room with 5 to 8 children aged 13 to 30 months, there should be 2 trained caregivers. There should be no more than 8 children aged 13 to 30 months in a room. For guidelines for on proper caregiver to infant or baby ratio, visit this link.
2. Environment should foster children’s growth and development. Children should be motivated and energized as well as have abundant exposure to games, songs, and conversation to foster sensorimotor and language development skills among other qualities. 
3. Safety, health, and hygiene should be a priority. Day care providers should have clear guidelines for cleanliness, such as hand washing after diaper changes and before meals. Toys should be disinfected on a regular basis. The facility must be childproof. All children and staff members should have current immunizations; staff should have clear criminal backgrounds checks.
4. Competent staff. Good signs are caregivers that are knowledgeable about infant development, low staff turnover, high moral and evident enthusiasm. 

Talk to other parents

One of the best resources for parents is other parents. It is encouraged for parents to talk to neighbors, friends, relative, and coworkers about their day care experiences and ask for recommendations.

Pediatricians also are able to provide excellent recommendations such as types of day cares, address concerns about cognitive development, social-emotional issues, communicable illness, and facets of high-quality care.

After all your research, interviewing, and observing is done it is important to determine if leaving your child in the care of someone else is what works best for your family. 

Having a sense of guilt is normal. It is typical for any new mother returning to work to feel fatigued and to experience a sense of loss over leaving her new baby in someone else’s care.

Don’t let that feeling bring you down however. You’ll need some patience to get through a period of adjustment. And recognize the advantages of quality child care – children are developing relationships with other kids and enhancing their social skills. 

Resources: www.naeyc.org; www.zerotothree.org ; www.aap.org; www.parents.com; www.workingmother.com

Written by Joanna E. Betancourt MD., FAAP

Vision Screen – An important part of your child’s wellness

We often encounter parents that think that children only need check-ups when they are due for vaccines. Although vaccine preventable diseases are an important part of the wellness checkup, there are many more things to evaluate, test and screen that are equally important in assessing a child’s health.

Among them are vision screens, which are often an overlooked aspect of child’s development. Eye examinations and vision assessments are vital for the detection of conditions that result in problems with school performance or in some cases, life-long visual impairment.

Early detection of treatable eye disease in infancy and childhood can have far reaching implications for vision, learning and social development and, in some cases, for general health.  

The American Academy of Pediatrics as well as the American Academy of Ophtalmology recommend that "examination of the eyes should be performed beginning in the newborn period and at all well-child visits."  

Because children do not complain of visual difficulties, vision screenings in an important part of the complete pediatric eye care. 

At Salud, we perform two different types of vision screen. The first one is the most common and one that probably you are familiar with, which is the vision acuity screening. This is the one where shapes and letters are displayed on a chart and patients stand about 10 feet away with one eye covered reading the letter or shapes.  

The other vision screen we perform is more high-tech. We conduct the Enfant Pediatric VEP Vision Testing System which is a child-friendly, non-invasive medical device that does not require sedation or dilation. This high-tech device gives us an objective method to test children as young as six months of age for visual defects such as optic nerve disorders, amblyopia (also called lazy eye), and conditions that can lead to amblyopia. 

As always, if you have any questions about these tests, feel free to call our office. If your question is a little more involved and you have a specific question about your child, you may need to make an appointment to discuss further your issue.  

At the very least, it is great piece of mind to know that your child has perfect vision which will allow him/her to reach their maximum potential.