You would think sending a bill to the insurance company would be simple. The doctor sees the patient then submits the bill and the insurance company sends a check. If only it was that easy. Billing is complicated. Insurance companies speak in codes. If you don't submit the correct code on the claim, it doesn't get paid.
And just when we thought it couldn't get worse. Now, we have to deal with healthcare reform. One question we hear is "Why can't you tell me exactly what I owe?" or "Doesn't my insurance pay for everything?" Healthcare is changing. The traditional PPO plans that many of us are used to, now have higher copays or even a high deductible. We also hear "My HR department said my well visit is covered 100%."
One of the biggest challenges in our practice has been with the Well Child Visit. Our practice follows the guidelines of the American Academy of Pediatrics and the Advisory Committee on Immunization Practices (ACIP). Under the Affordable Care Act, insurance companies must cover preventative services at 100% with no copay or deductible. However, they are finding ways around this. Many have their own list of preventive care "codes." If the doctor orders something, not on their list, it will be processed under a different benefit level. Now, what does this really mean? It's now the patient's responsibility either due to a copay or deductible.
And, there is more. What if you are in for a checkup and your child has an ear infection, breathing issues, or maybe school problems? If the provider spends additional time, makes a referral, or a prescription is written, this is no longer just a preventative visit. The doctor will charge for an office visit in additional to the "code" for physical exam. What if your child fails his hearing exam and additional testing is required? Unfortunately, the insurance company does not consider this part of the preventative service either. The "code" used to report this service is considered "sick." Part or all of the charge could be the patient responsibility depending on your coverage.
So, the question comes up again, "Why can't you tell me exactly what I owe?" We try hard to know what the rules are for the plans we participate in. But if the company you work for is self insured, nothing applies. They get to make up their own rules.
Frustrated? We understand. We are too! Our goal is to provide quality healthcare for your child. Our doctors are going to do what they feel is in the best interest of your child. Unfortunately, your insurance company may not agree with us.