The Offending Statement
"I just got a bill from your office. Why didn't you tell me little Jack's last visit wasn't covered?"
Yuck! The business of medicine: It's is not what I was trained to do and it's definitely not why I went to medical school. It used to be that pediatricians in practice had one nurse per physician—now, my medium-sized academic pediatric practice has one billing expert per physician. How times have changed!
Why We Don't Want to Hear It
Questions like this take up an enormous amount of administrative time and take me away from actually practicing medicine, so when billing, coding, or charging issues come up at our appointment, excuse me if I cringe!
The most common answer to your billing questions: I have little to no control over your insurance company. Your insurance company is not a good communicator, especially when it comes to changes in your policy. I have no access to your family's health insurance policy details (what is a covered service and what is not), and once I put a charge (or claim) through to the insurance company, it cannot be changed or recoded. So, little Jack's one-week visit cannot suddenly be billed as an ear check.
Yes, if lots of one-week checkups visits are suddenly getting rejected and bills are being sent to patients, I hear about it, and the next time I see a newborn, I warn his parents about checking on their coverage. However, many times these coverage issues are impossible to predict, especially with my aforementioned lack of access to your insurance contract. For example, I cannot tell if your child's spacer (the plastic tube that goes with the asthma inhaler I just prescribed) is covered at CVS or some other medical supply store.
What You Should Say
Welcome to the new age of medicine! The updated rules:
- You are required to pay your co-pay before every service (chasing down unpaid co-pays costs a fortune).
- You are charged for telephone advice; you are responsible for taking the brunt of many of your medical costs (fewer and fewer services are being covered).
- You will be charged for not showing up to your scheduled appointment. (Some doctors are now charging for patients being late! How ironic!)
- You will accrue a service charge if you need to be billed (or if you delay payment).
- And you probably won't find a sympathetic ear when you call to complain to any of the involved parties.
So what to say and do? Buckle up and take charge. Talk to the billing expert in your pediatrician's office. Ask lots of questions. Know your insurance policy—read the small print and learn what's covered and what isn't. If you're unsure about coverage, call your insurance company ahead of time. Be specific and get the answer you are looking for before hanging up. For example, you ask: "My child is one week old. Is a check-up covered at this age?" You may receive this answer: "You are allowed six visits between one and five years old." What exactly does this mean? Some insurance policies refer to one year old as within your child's first year of life, while others define it as after your child turns one. Be thorough and get the precise answers you need.
Helping Parents Deal
The heathcare insurance system is incredibly convoluted with many flaws and potential pitfalls. You can no longer sit back and let the doctor's office sort it out with the insurance companies. Patients are increasingly responsible for more of the initial cost ("assumed risk") in addition to their premiums, and more and more health savings accounts (HSAs) exist now, in which patients must work through huge deductibles before insurance coverage kicks in. For their troubles, patients have significantly reduced premiums.
Parents need to become healthcare investigators rather than passive players in the transaction of their child's healthcare. Beware: Your child's one-week visit, two-and-a-half-year visit, five-year visit, seven-year visit, and nine-year visit may not be covered visits anymore. And your pediatrician will be the last to know.