As you may be aware, Federal law mandates that insurance companies cover all doctor visits for preventive (well) services at 100%. This means that no payment is due from you as long as the preventive portion of the care given to your child is usual, customary and reasonable with respect to parental concerns and time involved.
During well child visits, a parent may have additional concerns regarding a potential medical illness or condition. Likewise, the provider may find an abnormality that requires further investigation. Please understand that, in this case, the provider must code not only the preventive service, but also any other procedure performed as well as all additional diagnoses your child may have. This may be an ear infection, poor weight gain, rash, behavior problems, etc.
Providers are required to code all diagnosis observed in every visit including the well visit. Depending upon the diagnosis and other factors, the provider is required to submit to your insurance company a well and sick procedure code together for the same date of service. This will generally result in a co-pay or cost-share for the sick diagnosis portion of the visit. This may result in a co-payment or the visit may be applied to your deductible, both of which are your responsibility.
