Specialty
Pediatrics Billing
Pediatrics runs on well-child schedules and immunisation series, both of which are billed against payer rules that vary by age band — and against coverage that changes often.
What makes it different
The things that decide whether these claims get paid.
- Well-child visits follow a schedule the payer defines
- Periodicity schedules differ between payers and age bands. A visit a week outside the covered interval is denied on timing rather than on merit.
- Immunisations have product and administration components
- Each is billed separately, and administration is frequently the one omitted. Across a full immunisation series the loss accumulates quietly.
- Developmental screening is separately billable
- Screening and assessment services delivered during a well-child visit are reimbursable in their own right, and are routinely folded into the visit instead.
- Coverage changes more often than in adult care
- Children move between family plans and public coverage frequently. Eligibility verified at registration dates faster here than almost anywhere else.
Where the money goes
Four leaks specific to Pediatrics.
A healthy practice in this specialty collects around 96% of billed charges. Most of the gap below that is made up of these.
- Immunisation administration not billed alongside the product
- Developmental screening absorbed into the well-child visit
- Well-child visits falling outside a payer's periodicity schedule
- Coverage lapsed between scheduling and the appointment
| Measure | Result | Reference |
|---|---|---|
| Collection rate | 96.0%OK | > 95% |
| Days in A/R | 28OK | < 30 |
| Denial rate | 3.0%OK | < 5% |
| A/R over 90 days | 8.0%OK | < 10% |
Illustrative figures — not a client result.
Questions
Asked most often.
Why is immunisation administration missed so often?
Because it feels like part of giving the vaccine rather than a separate service. It is billed separately, and across a full series the omission is substantial.
How often should eligibility be rechecked?
At booking and again on the day. In pediatrics, coverage changes between the two often enough to matter.