To understand the importance of completing fracture care it is important to understand that pediatric bones are different than adult bones and fracture/break differently.  Thus, why you should visit a pediatric orthopedic office!

Children’s bones have more flexibility, open growth plates and tend to heal faster than adult bones. Typically, total fracture healing time is 8-12 weeks versus months in an adult.

The objective of treatment is to maintain alignment to allow for healing and regain full function. Common factors that determine initial treatment and follow-up care include patient age, fracture pattern, fracture location, and level of displacement

  1. PATIENT AGE – this may influence splint/cast option, need for surgical intervention or follow-up. For example, toddlers often need longer casts to encompass a joint due to the shape of toddler extremities.
  2. PATTERN – Fracture pattern influences the stability of the fracture and directly impacts treatment and follow-up.
  3. LOCATION – this can be the specific bone involved or the location of the fracture within the bone.
  4. LEVEL OF DISPLACEMENT – this is in reference to the level of abnormal position of the fracture. This does not apply to all fractures. Also, the above-mentioned factors directly impact the acceptable amount of displacement and treatment.

TYPICAL FOLLOW-UP:

Let me start by saying for good or bad, insurance rules the world!

In my first blog (before the pandemic) I addressed insurance language and what it means.

Why is a fracture considered a surgery/procedure?  The short answer is your insurance company has decided it is a surgery/procedure.

How does this affect me?  The Doctor, Nurse Practitioner or Physician Assistant will assess the injury or fracture and determine what needs to be done next.  This could be casting, bracing, physical therapy or a combination.  This assessment is an office visit and an office visit copay applies. Diagnostic x-rays are NOT included in the copay and go towards your insurance deductible.  The fracture care which is considered surgery/procedure goes toward your deductible.  If x-rays are done at an imaging facility or hospital, those services will go towards your deductible along with a radiologist service. The insurance rules remain the same no matter where services are rendered.

Insurance is complicated, there is no doubt about it. If you haven’t had to use your health insurance, wonderful! I would like to hopefully make navigating your health insurance a bit easier with some general information.

COPAY: This is the patient’s responsibility for the office visit or any procedure that your insurance company has decided that a copay applies to. This varies from insurance to insurance. Some policies have copays for labs, radiology, ER, hospital stays.

DEDUCTIBLE: The amount you pay BEFORE insurance will pay.

COINSURANCE: The amount you will pay ONCE your deductible is met. For instance, on an 80/20 plan, insurance would pay 80% of the contracted rate and 20% of the contracted rate would be your responsibility.

CONTRACTED RATE: Your insurance has a contracted rate of reimbursement for doctors, out-patient facilities, urgent care, hospitals and other care sites. The medical service is billed out according to the CMS (Center for Medicare and Medicaid Services) pricing per the region. If the medical facility is contracted with your insurance, they must follow the insurance company guidelines of contracted rates AND what is considered an office visit or procedural.

OUT-OF-POCKET MAXIMUM: Traditionally, this includes deductible and coinsurance but not copays. If you meet your out-of-pocket maximum, usually you will not have a copay.

CPT: CPT stands for Current Procedural Terminology. These codes tell the insurance companies what was done. Some codes will be considered procedural/surgical even when done in an office setting. This is determined by the insurance company and by the company buying the insurance.

ICD-10: The ICD-10 stands for International Classification of Diseases, Tenth Revision. These codes tell the insurance company why you are being treated. In complicated cases the order in which they appear are very important, because they will support the procedure.

In conclusion insurance companies rule the world!

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Next up: HOW TO TALK TO AN INSURANCE COMPANY AND BE HEARD.