Why Do I Owe Any Money for a Well Visit?

Since the Affordable Care Act was instituted, most insurance companies cover the basic cost of a well visit without any cost to a patient or family. This is true for most of our patients, but not all plans follow this rule. In addition, the majority of plans cover vaccines and vaccine administration without passing along a cost to you. 

When you come to our office for a scheduled well visit, it may include many different items in addition to doing an exam and speaking with you. For example, often we ask you to complete surveys regarding development, depression, risks for lead and tuberculosis. We may also do hearing and vision tests, check a hemoglobin for anemia or apply fluoride varnish to prevent tooth decay. All of these items must be reported to your insurance company using separate codes with separately associated charges. We must follow the rules of your insurance company in order for the work that we do to be processed correctly by the insurance company. 

We always send a complete set of codes to your insurance company first. When we get a response back from them (and you should get the exact same response called an EOB: Explanation of Benefits), we must follow their rules on what happens next. Sometimes they tell us that everything we sent them was a "covered service" included in the amount they pay us for the well visit. If that's the case, you don't owe anything for the services provided during your well visit. 

Many times, however, they come back saying that they will cover some items, but the rest is "patient responsibility." When that happens, they tell us exactly how much that we must collect from you. We then charge your credit card on file or send a bill or notification for the amount that your insurance company has told us that you must pay in the form of copay, co-insurance or deductible.  We do not arbitrarily make up this amount. Your insurance company tells us what to bill you as part of your plan and our contract with them. 

Occasionally the payer will tell us that this is a "non-covered service" in which case your insurance plan does not cover the service at all, and we must bill you for the work performed. All of the work we do at well visits is included in the American Academy of Pediatrics recommendations for preventive care according to the "Bright Futures" program.  All of our charges are set to cover our office costs to provide the best care to our patients and in keeping with industry standards. If you have an employer-sponsored plan that does not cover what we consider essential for good care, we will be happy to provide the pediatric evidence as to why they should cover items such as depression and developmental screenings. 

If you ask us to treat something that is not part of a well check-up (such as freeze off a wart, or treat an infection), it will most likely be associated with the same payment responsibility (copay, co-insurance or deductible) that you would have paid if you had come in for that problem alone. For more information on this situation, see our article here. And for good information on copays, co-insurances and deductibles, we recommend this reference on the AAP's parent website. 

As always, please contact us with any questions you have. Thank you for the opportunity to partner with your family to make sure your children get great care.