Billing & Insurance

Understanding Your Wellness Visit

In an effort to optimize the health of our patients, Lancaster Pediatrics recommends regular wellness visits (also known as preventive exams or physicals) per the American Academy of Pediatric guidelines.  This document is provided to help patients understand the difference between what is covered within a Wellness Visit vs. Problem Oriented Visit.

Screening – services provided at wellness visits allow us to screen for many medical conditions such as developmental delays, appropriate height and weight gain, review appropriate immunizations and allows us to begin treating any condition in its earliest stages.  During these 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.  It is your responsibility to understand what screening services are covered by your insurance plan.

Insurance Coverage for Wellness Visits vs. Problem-Oriented Visits – You are likely aware that health care reform changes have directed that your insurance company no longer applies a co-pay and/or charges toward a deductible or co-insurance for many wellness and preventive services, including your wellness visits. We hope that this prompts more families to take advantage of their coverage for preventive services.

Although most wellness services are charge-free, this is not true of problem-oriented services. Some common examples of problem-oriented services include evaluation of ADD, ear infections, sinus congestion or prior visit concerns, etc. We strongly encourage that these seemingly minor issues receive due attention.

Insurance company billing policies dictate that we differentiate between these two types of services. Management of medical diagnoses, including the need for medication refill of any sort, is categorized by insurance companies as a problem-oriented service. Evaluation or management of any complaint or symptom offered by a patient or identified upon questioning during a preventive exam constitutes a problem-oriented service as well. Problem-oriented services always require a co-pay/co-insurance/deductible, if applicable to a patient’s insurance plan.

Due to the comprehensive approach to care taken by Lancaster Pediatrics, wellness visits may uncover or revisit problem-oriented issues that require evaluation or management. It is their preference whenever possible to go ahead and address such problem-oriented issues at the same office visit. As a result (unless patients desire to return at a later date to address the problem-oriented issues) frequently (during wellness visit) services are performed that are both preventive and problem-oriented in nature. This is also an additional convenience so that the families do not have to return to the clinic for another appointment. In compliance with insurance company billing policies, this then prompts charges for both categories. While preventive services do not require a co-pay/deductible, problem-oriented services do prompt a co-pay/co-insurance/deductible.