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, Dr. Dael Waxman at Elizabeth Family Medicine. He explained 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. My doctor 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.
In the past year or so, 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-pay from the patient.
“It’s very confusing, even for the doctors,” said Dr. Dino Kanelos of Carolina Family Healthcare in Ballantyne. “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 may save their questions for the preventive exam, hoping they can avoid paying the full cost of a separate medical visit.
“It’s a Catch-22,” Kanelos said. “I want to be able to say, ‘What’s going on? Is there anything wrong with you?’ In the old days, that’s the way I picked up a lot of problems. ... Now, it is hard to figure out what to do.”
Puzzling to patients
Because this is confusing to patients – and has led to more than a few objections like mine – Charlotte-area doctors have begun sending notices in advance, letting patients know they could be charged extra if they bring up questions that aren’t considered part of a preventive exam.
Kanelos’ patients not only get an email in advance, but on the day they arrive, they’re asked to initial items on a second document. Here are two of the choices:
I choose to have only the services performed which are included in the basic preventive exam.
I acknowledge that I may ask my provider to evaluate and manage my medical problem(s) during my preventive exam and that this treatment will result in a separate office visit to be billed in addition to the preventive exam.
In Mount Holly, Riverbend Family Practice also has begun sending a two-page form to patients in advance of preventive exams: “This visit is designed to educate you on changes you can make to live a healthier life and to identify new health problems. This office visit is NOT designed to address specific complaints or to manage known medical issues.”
The Riverbend notice explains that a preventive exam covers a review of immunizations, habits such as smoking and exercise, diet, and screening tests for colon cancer, breast cancer and diabetes. But it also says a preventive exam covers “past medical history” and “interim medical history since your last physical exam.”
Wait a minute? It’s hard to see how I could have discussed my “past medical history” without someone mentioning cholesterol. As a patient, I’m beginning to wonder why I’d even want a preventive exam if I can’t talk about things that aren’t on the doctor’s list.
Every doctor I talked to stressed the value of preventive exams. But they all admitted the coding issue is “complicated.” Some of them blamed insurance companies.
Colleen Dey, Kanelos’ office administrator, said insurers seem to have strictly adopted the list of preventive services outlined in the Affordable Care Act.
“They seem to be saying, ‘We’re required by law to cover these tests, so that’s all we’re going to do,’ ” Dey said.
But insurers say it’s up to physicians to decide which codes to apply for billing purposes.
“We don’t tell a provider how to code,” said Lew Borman, a spokesman for Blue Cross and Blue Shield of North Carolina. If a pre-existing problem is addressed, “then the additional charge for the exam can be reported,” he said.
“By reporting this way, the provider is indicating that a significant, separately identifiable service was rendered,” Borman said. “The medical records should document the additional work. If it is not documented, it should not be billed.”
Screening for cholesterol is part of a preventive exam.
“But if you have a history of elevated cholesterol, all of a sudden that becomes a diagnosis,” Waxman explained to me.
“For you, obviously, cholesterol is prevention, trying to prevent a heart attack,” he said. “If I was the patient, I could easily see myself thinking that. But in the medical world, it’s a diagnosis. ... That’s no longer a preventive screening issue.”
Dr. William Belcher with Blakeney Family Physicians said he’s seen “a lot of backlash from patients” over this issue.
Because so many patients today are covered by high-deductible insurance plans, more of them are “on the hook for everything,” Belcher said. “When you have the ability to see your doctor for free, for a preventive exam, it’s very tempting to ask (other questions).”
“Technically, the billing is ultimately up to the physician,” he said. “There’s nothing wrong with discussing minor issues during a wellness exam.”
Belcher and other doctors 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.
“I usually try to avoid billing the extra visit,” Belcher said. “It can just create bad karma with patients.”