Billing & Your Visit: What You Need to Know

"Can you also take a look at…?" Combining visits

There is a misperception that one can get as many things seen as possible during a physical or well child visit. A preventive visit covers screening and assessments of your child's development. Addressing issues and concerns are not part of the preventive visit and are handled the same as a separate problem.

If you come in with a long list of items to address, it is highly likely that the provider will not be able to address all of the items in the allotted time or there may be additional charges. For example, if you schedule an appointment for a sore throat but in the exam room ask that the provider remove a wart, the wart removal is considered an additional service.


Unscheduled siblings of scheduled patients

Please note that, as required by the CPT system and insurance regulations, each patient (not each family) is treated separately. Each child seen must be charged for a visit. Two children seen require two visits to be charged, three children require three to be charged, and so on. We do not feel that we can adequately evaluate a sick child by "just quickly look(ing) at his throat" or "just do(ing) a throat culture," as some parents request. Inevitably not only do the child and family get rushed care, but all the ensuing patients that day also get unfairly rushed, after having an extra wait, as we try to get back on schedule. Therefore, we honor the CPT/insurance company policy by following their directive and asking that parents not bring unannounced and additional children to a single appointment (even for a "quick look").

With advance notice we are more than willing to find the time to see as many children in a family as need to be seen, and to spend as much time during a visit as a family wishes. Please let the receptionist know of that need when you make your appointment so that we may schedule the appropriate amount of time for them. Remember, in the rare case that a walk-in or fit-in patient is seen, an extra surcharge (CPT code 99058) must be charged. This very significant fee is generally not covered by insurance or HMO policies, and is therefore the family's personal responsibility.

"Is this covered?"
Discussing benefits

It is impossible for your provider to know the details of your insurance plan. Each employer that offers health insurance to its employees has a unique contract with the health insurance company. Thus, there are thousands of subtle differences even within the same insurance carrier. Even your insurance will not guarantee coverage prior to the claim being processed. If you hear a provider say something like "I think it's covered" or "your insurance should cover this," don't believe them. They don't know. If you have questions regarding your insurance plan our billing staff would be happy to assist you in contacting your insurance to check your benefits, but your insurance will make the final coverage determination when they process your claim.


Follow-up visits

The current CPT system does not allow for "discounted" follow-up visits – each individual encounter with each individual patient must be coded based on the criteria outlined above. 

Medical care also does not lend itself to "lifetime" or "money-back" warranties. We do our best to take care of all our patients' physical concerns as completely and "permanently" as possible in just one visit. Some problems tend to recur, some change over time, some are very complex, some mimic others, some are slow to declare themselves, and new ones can crop up, all of which may necessitate further visit(s) for further evaluation and/or a change in management. Moreover, there are some medical illnesses, by their own merit, which properly require ongoing follow-up visits. None of us are happy about the time required of patients and their families when this happens, but it is a reality that doctors and patients alike must live with.

Hospital charges

When the pediatrician examines your child in the hospital, they may not always have the chance to visit with you about your child's exam. Even if you don't personally see the pediatrician, be assured that your child has been examined each day they are in the hospital, per hospital requirements. These services will be billed.


Some content courtesy of Utah Valley Pediatrics.

Essex Office One Wildwood Medical Center
35 Saybrook Road
Essex, CT 06426
Tel: 860.767.0168

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