Our physicians are contracted with most major health plans. If the doctor you are scheduled with is not contracted, you may still qualify for out of network coverage. Call your insurance plan to find out the details of your coverage. Our clinic cannot guarantee that your insurance will cover your services here, and our staff are not able to quote your benefits to you. Please contact your insurance carrier for more information.
Suggested questions to ask your insurance company:
- Does my plan cover naturopathic medicine or services rendered by a naturopathic physician?
- Is my selected doctor (Gray, Kass, McDaniel) a preferred (in network) provider? If you need the doctor’s NPI or tax ID in order to get verification, please call the office — our front desk can provide this information.
- If they are not in network, do I have out-of-network coverage? How will my care be covered out-of-network?
- Do I have a deductible, and how much is remaining?
- At what percentage will my insurance cover my care?
- What are my preventive benefits?
About billing for well child visits:
The services provided as part of a well-child checkup are generally defined by the health insurance company. These checkups include an assessment of growth and development, screening for medical and psychosocial problems, anticipatory guidance to aid parents in the next stage of their child’s development, a review of your child’s vaccination history and status and administration of any vaccines necessary. We are happy to address questions that come up during the visit, and most can be answered simply and fall within the scope of this well child checkup.
Sometimes, a more significant health problem will be identified over the course of this visit. If so, the time and effort spent addressing these concerns go beyond the scope of what is covered by a well-child exam. Some examples include:
- a new problem that requires diagnostic testing, referral to a specialist or sub-specialist, significant change in treatment for an existing concern, or prescription of a new medication. For example, at a 9-month baby visit, baby John is weighed and measured and is found not to have gained weight appropriately. Lab testing is done to check for anemia and a special feeding plan is set up.
- an in-depth discussion of a chronic medical issue that requires a detailed review of the existing treatment plan, and/or a change in treatment or a new diagnostic workup. For example, young Cara has congenital hypothyroidism and is on thyroid hormone replacement. Her recent labs are reviewed and her growth is assessed and a change is made to her medication. She is also referred back to Endocrinology for follow up.
When one of these scenarios arises, your doctor will typically submit billing codes for both a well-child visit and a “modifier” that indicates that an illness or problem was treated in the same visit. This is standard billing practice among all primary care providers and is accepted as standard practice by government agencies and by private health insurers. While most plans cover preventive care in full with no co-pay, there is often a co-pay, co-insurance or deductible associated with the “modifier” billing codes.
It is important to review chronic health conditions, so we encourage you to schedule this visit separately if possible.
About billing for routine adult preventive exams:
As described above for well-child visits, the topics expected to be covered during a routine adult preventive exam (“annual physical”) are defined by the insurance companies based on the age and gender of the adult. These generally include screenings for health problems and ordering certain tests appropriate for your stage of life.
If you have significant medical concerns outside of those, and they are treated with new medication, tests, or referrals, your doctor will typically submit billing codes for both a routine physical and a “modifier” that indicates that an illness was treated in the same visit. This is standard billing practice among all primary care providers. These modifier codes are accepted as standard practice by government agencies and by private health insurers. Though routine preventive care is often covered at 100% without a co-pay, your insurance company may require that you pay a co-pay, co-insurance, or deductible of this secondary portion.
Example: a 45-year-old man is found to have high blood pressure during his routine visit. A diet and exercise plan is set up, recommendations are made for home blood pressure monitoring, labs are ordered, and a supplement or medication is prescribed. He is asked to return for follow up. This is a new diagnosis involving management that goes beyond the scope of routine preventive care.