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Well-Child Exams and Payer Rules

Well-Child Exams and Payer Rules

For us and our staff, the stress of following the conflicting rules of various payers is taking its toll. Take for example scheduling the routine well exam.

Every week, we send emails to patients who will be due for a well exam in about three months. For 10 years, this system has worked well for us since many families usually don't know their sports, vacation, work, and other family-specific schedules any more than three months in the future anyway. Families who schedule three months out rarely cancel or reschedule like families who book a year ahead. As an added bonus, this also means that we don't have to know our personal sports, vacation, work, and other family-specific schedules a year ahead either (we only open up the schedule four months into the future).

This system works for us, but we've noticed that our simple, "Call us for a well exam" email has morphed into a long, rambling email over the years thanks to the craziness that is our American multi-payer system. Here is what we currently email to families when their children are due for a well exam:

We are contacting you because <Patient_First_Name> is due for a well exam in about three months.

Our first available appointment is currently six weeks in the future; our first after-school appointment is about two months in the future.

Clinically, Dr. McAllister recommends well exams one year after the last exam (sooner for children age 2 years and under). If for logistical reasons you wish to schedule sooner than one year, it's okay with us, provided that you verbally accept (with our scheduler) the risk that the appointment may not be covered by your insurance plan, leaving you with a self-pay bill.

To complicate scheduling, some plans contractually require that we see all their patients prior to the end of each calendar year. If you fall in this category, we may contact you to schedule an appointment as soon as possible, so that there is no possibility that we'll miss the end-of-year deadline.

It's enough to make your head spin!

Speaking with patients about this is challenging as well. There is a surprisingly large number of parents who express frustration and even anger that we would warn them about the possibility of a self-pay situation if they schedule early. "Not my plan!" they exclaim as if it's an insult to them personally to even suggest that they would have such a plan. How do we explain to these families that they would feel quite differently if they received an unexpected bill from us for the well exam?

Add to this the high number of parents whose OCD dictates that the child's well exam be the week of the child's birthday (not a medical requirement) and our independent practice association's (IPA) preference that we allow parents to self-schedule online, and now you're starting to understand our daily nightmare when scheduling a routine well exam.

 
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