Patient alert: If you’re going to your doctor for an annual preventive exam and expect it to be covered 100 percent by your insurance company, think again.
You could be charged for an extra “office visit” if you ask questions about existing medical problems, such as high blood pressure or cholesterol.
It happened to me in 2012 when I saw my family doctor for an every-other-year checkup. My insurance paid $256, the total for the preventive exam. But the “explanation of benefits” showed that I also owed $74.60, my share of the $113 bill for an “office visit” — on the same day, in the same time slot.
Puzzled, I called my doctor, Dael Waxman at Elizabeth Family Medicine in Charlotte, N.C. He explained that the second charge resulted from our talk about my elevated cholesterol level, which had been diagnosed previously. Because he documented that discussion and marked the billing code for evaluation and management of a cholesterol diagnosis, I was billed for the second visit.
I objected, believing that I should have been able to talk about cholesterol at a preventive exam. Waxman pretty much agreed. And because I hadn’t been made aware in advance of the second charge, he deleted it from my bill. I have learned since that it’s not unusual to get this extra charge with a preventive exam.
Primary care doctors say they have struggled over how to manage their time during preventive visits when patients bring up questions about chronic medical problems. If the discussion in a preventive exam turns to previously diagnosed conditions, the code for that signals the insurance company to pay for an “office visit,” which usually means a co-payment from the patient. “It’s very confusing, even for the doctors,” said Dr. Dino Kanelos of Carolina Family Healthcare in Ballantyne, N.C. “I just finished (a preventive exam) with a lady who had 15 medical problems she wanted to discuss.”
There are multiple factors at work here. This practice of billing for an extra visit began before the Affordable Care Act’s insurance mandate took effect Jan. 1. But some doctors and insurance companies may be using this opportunity to more strictly follow guidelines about what qualifies as a preventive service under the act and must be covered 100 percent without patient cost-sharing.
In addition, doctors are under pressure to document everything appropriately in the electronic medical record or they could be subject to Medicare reimbursement cuts in the future. That takes more time, so they have less time to handle extra questions from patients.
And with the growing prevalence of high-deductible insurance policies, patients might save their questions for the preventive exam, hoping they can avoid paying the full cost of a separate medical visit.
Medical professionals suggest patients talk to their doctors ahead of time to get an understanding about how extra medical questions will be handled. Maybe patients will choose to schedule a medical office visit instead of a preventive exam.