We can really make a difference in the world, just one heart, one kind word at a time. –Noelani Musicaro

It’s another birthday for PWG…and we have so many reasons to celebrate! Thanks to all the kids we get to see every day who make us smile, thanks to our wonderful team of providers for all their hard work, and thanks to our incredible support staff for their positive attitude. Dr. Eileen and I are very grateful that our vision and passion for pediatrics has resonated with so many of you, and we thank you for your continued support of Pediatric Wellness Group.

It’s our 3rd birthday, time has just flown by…but here’s wishing all of us many more Happy Birthdays together!

Dr. Niki and Dr. Eileen

We have just been notified by Blue Shield that Pediatric Wellness Group is a contracted provider with their individual health insurance exchange plans that are currently being offered through Covered California. This change is effective immediately and will be retroactive to 1/1/14.  If you have this insurance and came to our office and received a bill that states we were out of network at the time of your visit, please call our billing office at 650.288.0600 option 7, or email them at billing@pwgrwc.com.

NOTE: at this time we are only participating providers for Blue Shield and Health Net for individual plans being offered through Covered California.

As always, thank you for your patience as we worked through this. We are happy we were able to make this work for our patients and their families!

We’re getting calls from some of our patients with questions about recent EOB’s they received after a visit to our office.  They used to come here and have those visits covered, now they are being told we are out-of-network and their visits are covered at a much lower rate. We are just as confused about these changes and have spent lots of time on the phone with different insurance carriers to clarify how these changes will impact our patients.

if you are confused about the topic of insurance in general there are several great resources: the Robert Wood Johnson foundation has this guide, there are articles by the Boston Globe and CNN, and even About.com has this answer.  But you should also confirm your coverage with your insurance carrier.  Some people have been moved from their existing plan to one that is more restrictive, and PWG may not be in that network.

Some insurance companies have sold or consolidated their networks which have also resulted in more restricted networks, and once again PWG may be considered out of network. Our billing company just sent us this information:

This is in regards to patients with the Sutter Select UMR, not the UMR administered by UHC.  Effective 01/01/14 these UMR POS policies were absorbed and all switched to UMR EPO policies.  Since we don’t have a Sutter Select contract, we are out of network.  And since we are not Sutter affiliated there is no way to obtain a contract.  I checked the card and there are the PHCS and First Health network on there as well.  The representative told me the PHCS was for ER services outside of California and the First Health was for ER services within California.  Therefore, there are no out of network benefits.

Quickest way to distinguish the UMR Sutter Select patients is that most of the ID # start with the letter Y or will have their employer in the top right hand corner on the front of the card which is Mills Peninsula

If you have any insurance or billing questions feel free to call our billing office at 650-288-0600 option 7, or email them to billing@pwgrwc.com.

The incidence of head injuries are rising for student athletes at all levels of play. One study estimates 4 to 5 million concussions occur annually, with increased rates emerging among middle school players.  Students who had multiple concussions took longer to recover.  In California as of January 2012  a new law became effective that required a child suspected of having a concussion or head injury to obtain clearance from a health professional before returning to play. But it can be difficult to diagnose and manage concussions in kids, many of them are active and competitive athletes who simply don’t want to stop playing sports.  Studies have shown kids may minimize their symptoms or even skip reporting them altogether.

At PWG we have been using ImPACT testing to help us evaluate and manage concussions in our patients, and it has been a very safe, reliable and effective tool.  ImPACT is a 20 minute computerized program developed by the University of Pittsburg Medical Center to assist in concussion management.  The test measures your child’s verbal memory, visual memory, processing speed and reaction time.  It is used as a tool when evaluating your child for a concussion.  ImPACT does not diagnose a concussion, but informs the provider if there is a change in the way your child’s brain functions after an injury.

We are now starting a baseline testing program for our patients ages 11 years and up. We are offering this non-insurance covered testing for a rate of $35/person.  Each baseline ImPACT test will be  reviewed by one of our certified ImPACT consultants, Dr. Eileen Chan or Dr. Niki Saxena, for validity.  If it appears that your child’s test is invalid, you will be notified by phone to discuss the findings and it may be recommended that your child retake the test; in that case the re-test fee is $25.00.  You will be given a copy of your child’s ImPACT test results to keep for your records.  Sleep can affect the baseline results, so make sure your child is well rested prior to any baseline testing. Most insurance companies cover post-injury testing if your child sustains a concussion.

If you are interested in getting a baseline ImPACT test for your child, please call our office at 650.216.7794 to set up an appointment. This is another way we can foster wellness in our kids.

It is a very important form to fill out. For those of you with dual insurance coverage, you may have already gotten this form in the mail. According to the wisegeek: Coordination of benefits is a practice used to ensure that insurance claims are not paid multiple times when someone is insured under multiple insurance plans. The idea behind it is that someone on multiple plans might be tempted to submit claims to all of them, pocketing the excess cash.

Why does this matter at your pediatrician’s office? Again, the wisegeek says it well: Children can also be covered under coordination of benefits, with the “birthday rule” usually being used to determine which insurance company is the primary insurer. Under the birthday rule, the insurance company associated with the parent with a birthday earlier in the year would be the primary provider for the children. If Bob is born in January and Sue is born in March, Bob’s insurance would be the primary provider for their children.

What happens if you don’t fill it out? The insurance companies won’t know which plan is the primary plan for your child, and we have no way of looking up that information in our office. When we see your child in the office, that generates a claim that gets sent to your insurance company. Without this form those claims can get rejected, then we get a message saying your child “is not eligible for benefits so the claim is not covered”, and then our billing software may assume you are responsible for the full amount and will send you a bill.

It can take time to straighten out the confusion once that happens, and that means a delay in payments. Why is that important? Because we are a small business with 18 folks on our payroll…those folks need to be able to pay their own bills. A delay in payments can potentially impact their paychecks. So, a small form can have major consequences for us!

We hope this helps, and feel free to contact our billing office if you have any other billing or insurance questions: call them at 650-288-0600 option 7, or email them to billing@pwgrwc.com

Pediatric Wellness Group is proud to have received the highest certification from NCQA as a patient-centered medical home.

PWG receives NCQA Patient-Centered Medical Home Certification

June 27, 2013 was a special evening for us at PWG. The San Mateo County Medical Association held its Annual Meeting of Members at the Burlingame Country Club. It is my honor and privilege to now be inducted as the President of the San Mateo County Medical Association for 2013-2014.

I have been affiliated with this organization since I began my pediatric practice in San Mateo County in 1996. In the beginning I called on them for practice support and advice, then in 2008 I was invited to join the Board of Directors. That was when I got a much bigger picture of all the different activities that the SMCMA (and it’s parent organization the California Medical Association) does on behalf of physicians and their patients. It encompasses everything from advocating for legislation that protects both physicians and patients to pushing for education and awareness on current issues in healthcare.

This platform of awareness has convinced me that political advocacy for children is something I want to continue to do. Children can have a very faint voice in politics, and by speaking up on their behalf as a pediatrician I can help amplify that voice.

I want to thank Dr. Eileen for all her help and encouragement, she has been a tireless cheerleader encouraging me to keep going forward and speaking up. And a special shout out to the PWG team, their support gives me the time to spend on activities I feel passionate about.

Here’s to a good year for all of us 🙂 Dr. Niki