These days many families have high-deductible insurance plans, and the cost of healthcare services can be intimidating. Any efforts made by concerned providers to reduce healthcare costs are appreciated by our patient’s families. There is much we can do to keep parents’ out-of-pocket health costs to a minimum.
Physicians need to familiarize themselves with patients’ insurance plans. This information is readily available in the patient’s electronic health record (EHR). In general, patients with Medicaid health plans have little responsibility for healthcare expenses. In contrast, parents with either private, employer-provided insurance, or Affordable Care Act (ACA) insurance must pay thousands of dollars toward healthcare expenses until their deductibles are met.
Office visits to pediatricians for non–preventive care visits can total in the hundreds of dollars. This is not to say that are our fees are inappropriate, but many parents postpone visits for ailing children based on cost considerations. This is why we face stiff competition from walk-in clinics that are usually less expensive than physicians’ offices. (See https://www.cvs.com/minuteclinic/services/price-lists for CVS’ MinuteClinic price lists—and compare these to your own.) Although quality care from a familiar provider is considered by most parents a worthwhile investment, some may feel differently when they get your bill.
A medical practice usually adopts 1 fee schedule for all services provided. This is typically a multiple of the published Medicare fees established by the Centers for Medicare and Medicaid Services (CMS). Contracts with insurance companies determine what you get paid for each visit. Whereas a detailed discussion of office fees is beyond this scope of this article, most practices make sure that their fees are higher than the fees allowed by insurance plans to assure optimal payment.
There are, however, several circumstances for which physicians can provide services at reduced fees if circumstances warrant:
· First, a sick visit is charged by most pediatricians as a 99214 or a 99213 visit. This is based on several factors that include the number of problems addressed and medical decision making involved. Physicians do have latitude in charging a visit as a 99213 versus 99214 depending on how the visit is documented.
· Secondly, in many states, physicians can offer discounts for prompt payments. I would recommend checking with your insurance plans as well as your state health insurance department to see if this is allowed. If so, parents appreciate a reduction (20% to 30% is reasonable) in their bill, and prompt payment improves your office cash flow.
· Lastly, in most states, noninsured patients can be charged at a reduced rate. Again, check your insurance plans and the state health insurance department to check state regulations, but discounting a charge by up to 30% makes sense for the uninsured and makes seeking healthcare services from a primary care physician less foreboding.
In addition, because well visits are typically covered in their entirety by health insurance plans, minor problems can be addressed at these visits. If we discover an ear infection, for example, we can theoretically bill for a separate ill visit encounter—or not—depending on the amount of “extra” effort involved. Some physicians refill meds for attention-deficit/hyperactivity disorder (ADHD) at a yearly physical at no extra charge to the patient.
Best prices for services
Whereas the above can be controlled by providers, there are many external healthcare expenses beyond physician control. Services such as lab tests and x-rays are performed by local labs, imaging centers, or local hospitals, and these costs add up quickly. It is up to pediatricians to decide whether such tests are necessary.
Often experienced pediatricians can diagnose many conditions based on history and physical examination alone. We often don’t need x-ray confirmation of a suspected pneumonia. We don’t need a positive respiratory syncytial virus (RSV) test or complete blood count (CBC) to diagnose bronchiolitis. Each situation is different but, as we all know, we need to be careful and cautious depending on the age of the patient, the symptoms, and whether the result of a particular test makes a difference in the care being rendered. Liability factors into this decision as well. Patients with injuries often need an x-ray to rule out significant or subtle fractures. Patients with a history of prolonged or worsening headaches may eventually require a magnetic resonance imaging (MRI) study to rule out a brain tumor.