Types of Visits & Co-Pays

TYPES OF VISITS AND COSTS

    Pediatrics Associates of Wellesley commits to provide the best possible care for your family in a warm and responsive environment. While it is never easy to discuss the health of your children and money, it is important to know that we are a small, independent business.

In addition to the work we do with you and your children in an exam room, a great deal of work goes on behind the scenes at P.A.W:

  • Free telephone and email advice from doctors and nurses 24-hours-a-day

  • Prompt processing of insurance referral requests

  • Completion of school and camp forms as well as asthma and allergy action forms

  • Maintenance and transfer of medical records

   This is all in addition to the effort required to maintain our hard-earned reputation for running on time. In order to continue the valuable work we do with you and to support all the members of our team on whom you’ve come to depend, we must attend to money and the “bottom line.”

   We provide the following general guide to types of visits and payments to help you better understand your costs. These are guidelines that come from insurance companies. Your insurance company’s coverage may be slightly different and it is always important to know your benefits prior to scheduling a visit.

 

Sick Visit/Symptom Visit/Problem-based Visit

    This is an a appointment for a new problem such as a fever, cough, chest pain or anxiety or to monitor and manage a chronic issue such as asthma or ADHD. There are different levels (prices) depending on the time spent and complexity of problem.

    Does not include: Medication refills for other problems or review of preventative services             

    Insurance Coverage: These visits are covered by almost all insurance companies. Co-pay is charged and cost may be applied to deductible.

Well Child Exam/Routine Physical/Wellness Exam

    This is an exam on a healthy child with no symptoms to monitor growth and development, look for hidden disease, give advice on healthy behavior, and discuss and take preventative steps to promote continued good health.

    Does not include: evaluation of new symptoms and changes to management of chronic problems  

    Insurance Coverage: These visits are covered by most insurance companies without a co-pay. Costs may or may not be applied to deductible, however, if new medical issues are discussed or changes in management of a chronic conditions occur, there may be an office visit charge, for which a co-pay is charged and cost may be applied to deductible.

Nurse Visit

    This is a visit during which you will only see a nurse. Examples include the need for immunizations or blood work.

    Does not include: discussion of a new problem, evaluation from a doctor   

    Insurance coverage: co-pay may be charged and cost may be applied to deductible.

Coding for Insurance

    It can be hard to understand the way payments are made in the healthcare system and the different charges for different medical services. As a physician practice Pediatric Associates does not control these differences: our reimbursement is based on the coding system that insurance companies use to describe medical work. You may have had one visit with more than one service billed. An example is when you, your child and your doctor discuss an acute illness or new condition (like an ear infection or attention problems) at a well visit. The medical decision-making for treatment involves more than simply writing a prescription; it involves our judgment, knowledge and time. As such, the annual check-up and the evaluation and management for the illness may be billed as two separate services.

    To help understand this, think of work on your car. If you bring your car in for a routine service, you pay for a certain list of services. If at the same service appointment, you ask your mechanic to evaluate and repair a certain knocking sound, you would be charged for that added service, even though it is the same appointment.

    We at Pediatric Associates try to be judicious and respectful in our billing. We appreciate that heath care is not the same as car repair - both in its importance to you and the way for which it is paid.  Yet, again, in order to maintain an office that meets all your needs, we must attend to costs and revenue.

 

What is Co-pay?

    This is a fixed amount you pay for health care service when you receive care. The amount can vary based on your insurance or if you are on a tiered plan. If your insurance plan requires copays, we collect copay at the time of service, but it may be billed to you later if the type of visit changes based on what is done at the time of the visit.

What is a Deductible?

    This is the amount you owe for health care services before your health insurance plan begins to pay. For example, if your deductible is $1000.00, you must pay for any health care costs until that amount reaches $1000.00. After that, your insurance plan should pay costs in excess of $1000.00. Not all services are applied to your deductible. Well visit care is customarily not applied to your annual deductible