Why Do I Sometimes Owe Money When my Pediatrician Addresses a Problem or Concern During a Well Visit?


As your pediatrician, we want to see your child for well visits on a defined schedule that has been shown to promote their health and wellness. This schedule, endorsed by the American Academy of Pediatrics, is defined by a program called “Bright Futures” and it is the standard of care to make sure that every child has their best chance of a bright future. During well visits, we monitor your child’s growth and development, give appropriate immunizations, talk to you about important safety issues, and address your general questions and concerns. We also monitor for early signs of problems so they can be identified and addressed appropriately.

Other reasons for a visit to our office might include an acute illness (such as sore throat, fever, rash, abdominal pain or ear pain), a specific concern (such as toe-walking, not doing well in school, difficulty sleeping) or monitoring of a chronic medical problem (such as asthma, ADHD, diabetes, obesity, anxiety, or growth concerns.) Whether this is a concern that you raise or one that your pediatrician determines needs follow-up in order to provide good care, these are outside routine issues that are part of a standard well visit.

As your pediatrician, we must follow specific guidelines on what codes to submit to insurance companies to make sure that the care we give is appropriately processed by your insurance according to the terms and conditions of your policy. There are distinctly separate codes to describe what happens at well visits and what happens at illness/concerns visits. Most insurance plans cover the basic codes for well visits without you having to pay a portion of the bill. In contrast, most insurance plans require that the family has some cost sharing responsibility (co-pay, co-insurance or deductible) for illness/concerns visits.

Sometimes we will allow you to “combine” a well visit with a sick visit for your family’s convenience. For example, we may combine a well visit with an asthma or ADHD recheck. This convenience is often appreciated by our families in order to reduce missed school/work and other obligations. Due to the information that must be documented and sent to your insurance company, any family responsibility for payment that is part of your insurance coverage must be applied to the part of the visit that is not a routine part of routine well care. It doesn’t matter whether the well visit and the illness/condition visit are done on the same day or different days, any family payment must be collected as part of our contract with your insurance company. Some insurance companies will not pay for both items on the same day and we may ask you to schedule separate appointments on separate days. If this is the case, you may want to discuss this issue with your insurance plan.

It is not uncommon for your pediatrician or you to identify an acute problem at the time of a well visit. For example, the day of your child’s well visit they may wake up with a sore throat and fever. Or your child has a mild cough that you are not concerned about, but we hear wheezing which we determine needs treatment. If we address the acute illness at the well visit, we must record it separately and use different codes to submit to your insurance company.  In addition, you may ask us to freeze a wart or perform another procedure which may be applied to your deductible or trigger a co-payment/co-insurance. Those services that apply to the acute illness (perhaps a rapid strep test and writing a prescription for an antibiotic or nebulizer treatment and a prescription) will generate the same family payment responsibility that would have been charged if you had come in for those complaints on a day different than your well visit. 

Kressly Pediatrics wants to partner with you to make sure your child gets the most appropriate care. If you have multiple concerns that you wish to discuss at a well visit, ask us the best way to raise those concerns. If your child wakes up ill on the day of a well visit, call our office so we can make sure we are able to appropriately address the illness as well as make sure your child gets timely routine well care.  Please know that as your pediatrician, we must follow the rules of your insurance plan and that often includes family payment obligations when combining care for illnesses or conditions at the time of the well visit.