Insurance/Billing

• Aetna
• Blue Choice/Blue Choice Option
• Doctor’s Health Plan/ POMCO
• Lifetime Benefit Solutions
• MVP/ MVP Option
• Your Care
• Blue Shield
• Cigna
• Excellus
• Medicaid
• Tricare

As your pediatrician, we want to see your child for well visits on a defined schedule that has been shown to promote their health and wellness. This schedule, endorsed by the American Academy of Pediatrics, is the standard of quality care. During well visits, we monitor your child’s growth and development, give appropriate immunizations, talk to you about important safety issues, and address your general questions and concerns.

You may also visit our office for acute problems (cold, cough, ear infection, rash, wart), chronic health problems (constipation, allergies), to address a new developmental or behavioral health concern, or to review progress on a chronic condition (like asthma, diabetes, ADHD, obesity). Whether concern about these issues comes from you or your child, or your pediatrician determines follow-up is needed in order to provide good care, these are all outside routine issues that are part of a standard well visit.

As your pediatrician, we must follow specific guidelines on what codes to submit to insurance companies to make sure that the care we give is appropriately processed by your insurance according to the terms and conditions of your policy. There are distinctly separate codes to describe what happens at well visits and what happens at visits addressing illness or other concerns. Most insurance plans cover the basic codes for well visits without you having to pay a portion of the bill. In contrast, most insurance plans require that the family has some cost sharing responsibility (co-pay, co- insurance, or deductible) for problem-based visits and tests provided in the office.

Sometimes we will allow you to “combine” a well visit with a concern visit for your family’s convenience. For example, we may combine a well visit with a follow up for asthma or ADHD, or the removal of a wart. Due to the information that must be documented and sent to your insurance company, any cost sharing responsibility as determined by your insurance must be applied to the part of the visit that is not a routine part of well care. Any payment determined to be due must be collected as part of our contract with your insurance company. Some insurance companies will not pay for both items on the same day, and we may ask you to schedule separate appointments; if this is the case, you may want to discuss this issue with your insurance carrier, or your company’s benefits manager.

Occasionally, an acute problem, such as wheezing, an ear infection, or possible strep throat, might arise on the day of your well visit, or even be identified by your pediatrician during the physical exam. If we address acute illness at the well visit, we must record it separately and use different codes to submit to your insurance company. In addition, any diagnostic procedures – such as a flu or strep test, or a urinalysis – must also be sent to your insurance, and may trigger co-payment or co-insurance. Finally, national guidelines strongly recommend that we perform tests or questionnaires to ensure appropriate development and screen for mental health issues at well visits. Your insurance company may decide that the cost of these standard of care services is part of your financial responsibility. Any cost determined to be the family’s responsibility according to your insurance policy must be collected as required by our contract with your insurance company.

Pittsford Pediatrics wants to care for your family in the most effective and efficient way possible. If you have multiple or chronic concerns that you want to address at your well visit, be sure to raise them when you schedule the visit so we can plan your visit accordingly. If your child wakes up ill on the day of a well visit, call our office to make sure we are able to appropriately address the illness as well as make sure your child gets timely well care. Please know that as your pediatrician, we must follow the rules of your insurance plan, and that can include family payment obligations when combining acute care needs with the well visit.