Current Environment:

In the past couple of years, we have received an increase in inquiries about bills generated for service here at Needham Pediatrics. As many patients are now opting for or being directed to less expensive insurance plans, many patients now have high deductibles, larger co-pays, or limitations on covered services.

Below are some frequently asked questions about billing.

1: I am now receiving bills for services that were previously covered by my insurance. Why has Needham Pediatrics changed its billing practice?

Needham Pediatrics has not changed its billing practices in any substantial way for many years. What has changed is your insurance coverage. When you enroll in a health insurance plan, you are signing a contract that dictates whether specific health care charges are the responsibility of you or the insurer. We at Needham Pediatrics have no control over the specifics of this contract.


2: My child was seen for a well-child checkup. Why was I also billed for a sick visit?

Our contracts with health insurers dictate a certain level of payment for well-child checkups. Well-child checkups include an assessment of growth and development, a screen for medical and psychological problems, anticipatory guidance to aid parents in the next step of their child’s development, a review of the child’s vaccination status and updates as needed, and the generation of a “health form” that clears children for participation in school, sports, and camp activities.

In the course of performing a well-child checkup, your physician will be happy to address any specific concerns or questions that you have about your child’s well-being. Many of these are simple questions that can be addressed quickly and clearly fall within the scope of a regular checkup.

In some instances, a more significant health problem will be identified at the well-child visit, or a chronic medical issue will be discussed in detail. If so, the time and effort your physician spends addressing these health problems go beyond the scope of what is covered as part of a well-child visit. Some examples of such scenarios include:

  1. The recognition of a new medical problem requiring diagnostic testing, referral for subspecialty evaluation, and/or a new prescription medication.
  2. An in-depth discussion of a chronic medical issue requiring a detailed review of the treatment plan and/or a change in treatment or new diagnostic testing.

When these scenarios arise, your physician will generate a billing code for the well-child visit and a “modifier” code indicating that an illness was also treated at the same visit. This is standard billing practice among all primary care providers (pediatricians, internists, and family practitioners). Modifier codes are accepted as standard practice by government agencies and by private health insurers.

In the past, many health insurance plans covered these “modifier” billing codes in full. As insurance coverage has evolved, however, an increasing number of patients are now being asked to pay either the full cost of these modifier billing codes or a co-pay for the modifier portion of the total visit charge.

Again, our billing practices have not changed, nor has our contract with the insurers in this matter. What has changed for many of you is the contract you have signed with your insurer.


3. I understood that I have no co-pay for well visits. Why was I charged a co-pay for my child’s recent visit?

As per question #2 above, this scenario usually occurs when the patient was billed not only for a well visit but also for a simultaneous sick visit using a “modifier” code. Your insurance coverage may dictate that you are responsible for the co-pay for the sick visit portion of the bill. It is not our decision to charge you a co-pay. Your co-pay results from your contract with the insurer.


4. My insurance plan charges high co-pays and/or has a high deductible. Can Needham Pediatrics charge me a discounted rate for my visits to the office, since I am paying these costs out of pocket?

When we sign contracts with health insurers, we notify them of the rates we charge for the services we provide. Under the terms of these contracts, we are obligated to charge the same rates to all patients, regardless of what form of insurance they have. If we have a discounted rate for patients who pay out of pocket, we could be accused of billing fraud by the insurers, who might claim that we are charging them a falsely inflated rate. For this reason, we must charge all patients identically for the services we provide.

If you are having financial difficulties and cannot readily pay your bill at Needham Pediatrics, please contact our billing office. We will be happy to discuss the situation with you to see if we can help you arrange a workable payment plan.