Understanding office visit and billing practices
The physicians and staff at East Portland Pediatric Clinic are committed to providing and maintaining the best possible care for our patients. Your review of billing practices in advance allows for good communication and common understanding.
Insurance company billing policies dictate that we differentiate
between two types of services.
- Wellness Services
- Problem-Oriented Services
What may be included in Wellness Services (also known as
preventative visit or physical or well child check)?
- Age appropriate history
- Age-appropriate medical exam
- Anticipatory guidance (such as reducing fall risks for early walkers)
- Review and interpretation of any recommended labs
- Preventive counseling (such as proper nutrition)
- Review of vaccine history
What other preventive related services will be billed separately?
- Vaccine products*
- Routinely recommended labs**
- Vaccine administration services (including counseling)
- Screenings, (e.g., vision, hearing or developmental screens)
During wellness visits, we perform all recommended screenings appropriate to age and gender and seek to uncover any conditions that would lead to suboptimal health in the years to come. These screens are recommended by the American Academy of Pediatrics. The use of screening tools also allows us to begin treating conditions in their earliest stages. These screens are considered a problem-oriented service by most insurance plans and therefore may generate cost sharing in the form of a copayment, coinsurance, and/or deductible.
The Affordable Care Act makes many wellness and/or preventative services covered in full by most insurance plans. However, this is not true of many problem-oriented services. Management of medical diagnoses, including the need for medication refills of any sort, are categorized by insurance companies as problem-oriented services. Evaluation and/or management of any complaint and/or symptom offered by a patient or identified upon questioning during a wellness exam constitutes a problem-oriented service which may result in your insurance company processing your claim using both wellness benefits and problem-oriented benefits.
Problem Oriented Services
Some common examples of problem-oriented services include but are not limited to:
- Illnesses addressed (ears, eyes, nose, throat, cough, fever, etc)
- Age-appropriate medical exam
- Chronic conditions addressed (e.g., obesity, asthma, ADHD)
- Behavior Concerns
- Gynecologic concerns
- Lactation Services
- Suture Removal
- Wart removal
- Nail Excision
Examples of screening services include but are not limited to:
- Cholesterol, Lead, Hemoglobin Screening
- Vision tests
- Hearing screening
- Developmental Screenings (ie: 9, 12mo questionnaires)
- Mental Health questionnaires
- Adolescent questionnaire
- Autism screening (MCHAT)
**all laboratory, radiology and/or pathology services performed or referred by our providers may result in additional bills and/or charges from other companies that may include but are not limited to: Quest laboratories, Epic Imaging, Adventist lab etc.. You may receive separate billing statements for these services.
Our medical practice wants to provide the most up-to-date, comprehensive care possible, which is why we address these issues during wellness visits. Additionally, we try to eliminate the need for the patient to return to the office, whenever possible. It is the responsibility of the policy holder to be aware of their insurance plan’s benefits and coverage. Deductible, copay, coinsurance or out-of-pocket expenses agreed upon between you and your insurance company are out of our control.