Insurance coding/billing for annual preventive physical

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TSR
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Insurance coding/billing for annual preventive physical

Post by TSR »

After the pandemic and a recent move, it had been a couple of years since I went to a doctor for a check-up. I found a new doctor in the "family medicine" section of a major hospital group (in a new city and with a new insurance company). I called and asked for a check-up. When I went in, the doctor said, "This is for a check-up, right?" Yes. During the check-up, she asked how I was doing, was I experiencing any problems, etc. I made the mistake of telling her that yes, I was having some shoulder and back pain, among other mild issues that had shown up in the last two years. She ran some usual physical tests, ordered x-rays for the shoulder and back, referred me to other doctors for the orthopedic stuff, and ordered blood work, including a vitamin D test that she specifically warned might not be covered by insurance. Fine.

I have an HDHP plan that covers "preventive" care, including one annual wellness visit. I assumed that it would cover the office visit, some of the blood tests, not the x-rays, and not the vitamin D test. This assumption was largely correct (although there were a few coding errors in the labs), except for the visit itself, which was billed as follows:

1. Office/Outpatient New Low Mdm -- $200.00
2. Preventive visit, new, 40-64 -- $279.00

The second one of these was paid for by insurance, but the first I had to pay out of pocket (although it applied against my deductible and had a "contractual write-off" down to $165). Bear in mind that I only had one visit. After several phone calls, I learned that although "preventive" care was covered, discussion of things like shoulder problems was not, so that part was coded as an "office visit" and thus non-preventive. This was somewhat of a shock because I was only ever answering the doctor's questions about how I was doing. Some online research --- including a few older posts on this forum --- suggests that that my situation is not unusual. I'm a little shocked by this. Two broad areas of concern:

First, there's sort of a philosophical issue here: how does a single visit become two visits? Like, I can imagine a doctor saying "I can't ethically code some of this as preventive care, so I'll say that maybe 50% of this visit was preventive." But instead, there's a whole new visit, all of which I'm paying for. Lest we get lost in HDHP and coding madness, I think it's reasonable to imagine what would happen if I had no insurance and was paying entirely out of pocket. I go in there for a single check-up/physical and answer the wrong question, and then suddenly I'm billed for two different visits? I'd be livid. How does one visit become two?

Second, and perhaps more importantly, how does one interact with one's primary care provider knowing this? Do I state at the start of my next visit, "I do not wish to discuss any matters that may be considered non-preventive or that would trigger double-billing, and I would ask that you not ask me any questions about such matters?" Or does one have to refuse to answer each question as they come at the risk of being double-billed if you answer the wrong one? More importantly, isn't the whole purpose of the wellness visit to see how you've been feeling? Sure, preventive means "going forward," but don't you have to "look back" a bit too? How are you guys handling this stuff? Additionally, does this mean that I should never seek a referral during a physical, but rather should just go ahead and book an appointment with a specialist not even knowing if I have a major concern? For instance, I might normally say, "Doc, I've been having this dermatological issue. Do you think I should see a specialist, or am I overreacting?" But now it would appear that I've just asked an "office visit" question rather than a "preventive" question, right? I'd be double-billed for the "office visit" and the specialist visit, so why not just go straight to the specialist? This doesn't seem efficient. I've had an HDHP plan before and *never* been billed for anything discussed in a physical before, so this is new to me. If not every doctor does this, how would I find one that doesn't? Seems an odd question to ask up front.

Any advice is appreciated.
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ClevrChico
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Re: Insurance coding/billing for annual preventive physical

Post by ClevrChico »

You are being billed correctly. That is normal when things deviate at all from being "preventive". If you don't want to be billed for something, don't mention it. :happy
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TSR
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Re: Insurance coding/billing for annual preventive physical

Post by TSR »

ClevrChico wrote: Tue Aug 03, 2021 4:23 pm You are being billed correctly. That is normal when things deviate at all from being "preventive". If you don't want to be billed for something, don't mention it. :happy
Serious follow-up question: When you are in this situation, do you lie and say "no," or do you say, "I do not wish to answer any question that could result in me being billed twice for this office visit"? (Rhetorical follow-up: doesn't this sort of destroy the doctor/patient relationship?)
Broken Man 1999
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Re: Insurance coding/billing for annual preventive physical

Post by Broken Man 1999 »

OP stated: "....I made the mistake of telling her that yes, I was having some shoulder and back pain, among other mild issues that had shown up in the last two years...."

So, to avoid paying extra you think you made a mistake telling her your issues?

How would she know if you had issues? Was she clairvoyant? A fortune teller? A psychic?

Is your health less important than your wallet?

Why even go?

Broken Man 1999
“If I cannot drink Bourbon and smoke cigars in Heaven then I shall not go." - Mark Twain
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ClevrChico
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Re: Insurance coding/billing for annual preventive physical

Post by ClevrChico »

TSR wrote: Tue Aug 03, 2021 4:26 pm
ClevrChico wrote: Tue Aug 03, 2021 4:23 pm You are being billed correctly. That is normal when things deviate at all from being "preventive". If you don't want to be billed for something, don't mention it. :happy
Serious follow-up question: When you are in this situation, do you lie and say "no," or do you say, "I do not wish to answer any question that could result in me being billed twice for this office visit"? (Rhetorical follow-up: doesn't this sort of destroy the doctor/patient relationship?)
My advice would be to max out your HSA as much as possible and plan on having out of pocket costs, especially as you age. That's the reality of a HDHP and plan on spending several hundred or thousand annually.

You're not under oath at the doc, so you don't have to bring up anything you don't want to. (I'd be broke if I mentioned every body ache during my annual visit.) But, they don't work for free, and they're not double billing you, so plan on paying for anything you want them to look into.
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TomatoTomahto
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Re: Insurance coding/billing for annual preventive physical

Post by TomatoTomahto »

American healthcare is insane. Both patients and providers are to blame.

I use a concierge doctor because I don’t want to have to figure out how many billing codes can dance on the head of a pin.
I get the FI part but not the RE part of FIRE.
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TSR
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Re: Insurance coding/billing for annual preventive physical

Post by TSR »

Broken Man 1999 wrote: Tue Aug 03, 2021 4:29 pm OP stated: "....I made the mistake of telling her that yes, I was having some shoulder and back pain, among other mild issues that had shown up in the last two years...."

So, to avoid paying extra you think you made a mistake telling her your issues?

How would she know if you had issues? Was she clairvoyant? A fortune teller? A psychic?

Is your health less important than you wallet?

Why even go?

Broken Man 1999
I think that's my question. Should I take any questions that are unrelated to the exact things that are covered in a preventive visit directly to a specialist and not mention them to the PCP? Is that what other folks do? And if I fail to do this, why does the doctor treat it like it's an entirely new visit and charge accordingly? Again, I've previously had check-ups with an HDHP and not had this issue (in another town with another doctor), so this is all new to me.
Da5id
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Re: Insurance coding/billing for annual preventive physical

Post by Da5id »

I just hold my tongue and pay it. If something is bothering me I tell my GP during my physical. If they bill me for stuff, well, so be it. I don't assume that they are scamming me or violating their contract with my insurance company. I do skim the EOB and if something looks odd I'd ask a question, but generally it just is what it is. I value my health quite highly.
Notsobad
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Re: Insurance coding/billing for annual preventive physical

Post by Notsobad »

You want the best care for the best price. The doctor wants the best income for his services. Neither of you make the rules or set the prices.
Broken Man 1999
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Re: Insurance coding/billing for annual preventive physical

Post by Broken Man 1999 »

TSR wrote: Tue Aug 03, 2021 4:33 pm
Broken Man 1999 wrote: Tue Aug 03, 2021 4:29 pm OP stated: "....I made the mistake of telling her that yes, I was having some shoulder and back pain, among other mild issues that had shown up in the last two years...."

So, to avoid paying extra you think you made a mistake telling her your issues?

How would she know if you had issues? Was she clairvoyant? A fortune teller? A psychic?

Is your health less important than you wallet?

Why even go?

Broken Man 1999
I think that's my question. Should I take any questions that are unrelated to the exact things that are covered in a preventive visit directly to a specialist and not mention them to the PCP? Is that what other folks do? And if I fail to do this, why does the doctor treat it like it's an entirely new visit and charge accordingly? Again, I've previously had check-ups with an HDHP and not had this issue (in another town with another doctor), so this is all new to me.
Well, if you feel comfortable in doing a self-diagnosis such that you have the ability to select the right specialist, knock yourself out.

My PCP has been my source for referrals ever since I started with him. In fact, he is the PCP for some of my specialists family members. My PCP's office calls, and an appointment becomes available like magic when a call from DW yielded an opportunity months out. I told him one day he had quite a clique. He smiled and said I was in the same clique.

A good PCP does that for his/her patients. But, you must develop rapport, and mutual respect. Respect their time, they are your advocates. They can move obstacles insurance companies can erect.

Broken Man 1999
“If I cannot drink Bourbon and smoke cigars in Heaven then I shall not go." - Mark Twain
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TSR
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Re: Insurance coding/billing for annual preventive physical

Post by TSR »

Broken Man 1999 wrote: Tue Aug 03, 2021 4:47 pm
TSR wrote: Tue Aug 03, 2021 4:33 pm
Broken Man 1999 wrote: Tue Aug 03, 2021 4:29 pm OP stated: "....I made the mistake of telling her that yes, I was having some shoulder and back pain, among other mild issues that had shown up in the last two years...."

So, to avoid paying extra you think you made a mistake telling her your issues?

How would she know if you had issues? Was she clairvoyant? A fortune teller? A psychic?

Is your health less important than you wallet?

Why even go?

Broken Man 1999
I think that's my question. Should I take any questions that are unrelated to the exact things that are covered in a preventive visit directly to a specialist and not mention them to the PCP? Is that what other folks do? And if I fail to do this, why does the doctor treat it like it's an entirely new visit and charge accordingly? Again, I've previously had check-ups with an HDHP and not had this issue (in another town with another doctor), so this is all new to me.
Well, if you feel comfortable in doing a self-diagnosis such that you have the ability to select the right specialist, knock yourself out.

My PCP has been my source for referrals ever since I started with him. In fact, he is the PCP for some of my specialists family members. My PCP's office calls, and an appointment becomes available like magic when a call from DW yielded an opportunity months out. I told him one day he had quite a clique. He smiled and said I was in the same clique.

A good PCP does that for his/her patients. But, you must develop rapport, and mutual respect. Respect their time, they are your advocates. They can move obstacles insurance companies can erect.

Broken Man 1999
This is a helpful way to think about this. Thank you.
jeam3131
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Re: Insurance coding/billing for annual preventive physical

Post by jeam3131 »

The doctor is billing based on coding rules set by the government and the rates are set by your insurance company
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Re: Insurance coding/billing for annual preventive physical

Post by Jack FFR1846 »

Is the lab in plan?

I ask because I used my doctor's lab last year. The doctor works for "Joe's Doctors" and the lab is called "Joe's Doctors Lab". As it turns out, the lab is out of plan. This year, I asked to have orders written for "Ed's in plan Lab" instead and went there. There was a vitamin D test written. The informative lab person told me "Your insurance won't cover the vitamin D test. It's $240 that you will have to pay for". I said to skip that test. I did get a lab bill for something like $6.43.

I completely agree that medical billing is out of control. [Political comment removed by moderator Misenplace.]
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Re: Insurance coding/billing for annual preventive physical

Post by jeam3131 »

Jack FFR1846 wrote: Tue Aug 03, 2021 5:02 pm Is the lab in plan?

I ask because I used my doctor's lab last year. The doctor works for "Joe's Doctors" and the lab is called "Joe's Doctors Lab". As it turns out, the lab is out of plan. This year, I asked to have orders written for "Ed's in plan Lab" instead and went there. There was a vitamin D test written. The informative lab person told me "Your insurance won't cover the vitamin D test. It's $240 that you will have to pay for". I said to skip that test. I did get a lab bill for something like $6.43.

I completely agree that medical billing is out of control. [Political comment removed by moderator Misenplace.]
Medical billing is confusing. No question. But I wouldn't villanize the physicians. They don't set the rules and also deserve to be compensated for their time. How much would you like to be paid for a job that takes 7-11 years of post college training and 200k+ student loans?
Last edited by jeam3131 on Tue Aug 03, 2021 5:12 pm, edited 1 time in total.
abner kravitz
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Re: Insurance coding/billing for annual preventive physical

Post by abner kravitz »

TomatoTomahto wrote: Tue Aug 03, 2021 4:33 pm American healthcare is insane. Both patients and providers are to blame.

I use a concierge doctor because I don’t want to have to figure out how many billing codes can dance on the head of a pin.
How does using a concierge doctor change anything? I used a concierge doctor for a couple of years and the only thing that changed was access. The bills were the same except for the big yearly fee. Was I missing something?
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Re: Insurance coding/billing for annual preventive physical

Post by RickBoglehead »

:?
abner kravitz wrote: Tue Aug 03, 2021 5:10 pm
TomatoTomahto wrote: Tue Aug 03, 2021 4:33 pm American healthcare is insane. Both patients and providers are to blame.

I use a concierge doctor because I don’t want to have to figure out how many billing codes can dance on the head of a pin.
How does using a concierge doctor change anything? I used a concierge doctor for a couple of years and the only thing that changed was access. The bills were the same except for the big yearly fee. Was I missing something?
No insurance, that's how.
Avid user of forums on variety of interests-financial, home brewing, F-150, EV, home repair, etc. Enjoy learning & passing on knowledge. It's PRINCIPAL, not PRINCIPLE. I ADVISE you to seek ADVICE.
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TSR
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Re: Insurance coding/billing for annual preventive physical

Post by TSR »

Jack FFR1846 wrote: Tue Aug 03, 2021 5:02 pm Is the lab in plan?

I ask because I used my doctor's lab last year. The doctor works for "Joe's Doctors" and the lab is called "Joe's Doctors Lab". As it turns out, the lab is out of plan. This year, I asked to have orders written for "Ed's in plan Lab" instead and went there. There was a vitamin D test written. The informative lab person told me "Your insurance won't cover the vitamin D test. It's $240 that you will have to pay for". I said to skip that test. I did get a lab bill for something like $6.43.

I completely agree that medical billing is out of control. [Political comment removed by moderator Misenplace.]
The lab is in-plan, fortunately.

The last paragraph of your post is prohibited on this site as political discussion and will get the thread locked. I realize that my initial post may have seemed like complaining about "the system," but I really just wanted to know whether this was normal (sounds like it is!) and what people do about it.
musicmom
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Re: Insurance coding/billing for annual preventive physical

Post by musicmom »

Following this closely.

Ive had the same PPO medical plan for decades, now on its retiree version.
Yearly physicals were free and any/all issues would be discussed. Labs covered in network 100%.

This fall, I go on Medicare as primary, retiree plan will be secondary.
I know that Medicare has their well visit. I think thats the one I shouldnt discuss any issues.
Wonder if doc codes it as well visit AND office visit what the EOB from secondary will look like.
I'll find out.

At 65, I'm not going to STOP asking for medical advice from my PCP.
OnTrack2020
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Re: Insurance coding/billing for annual preventive physical

Post by OnTrack2020 »

Yes, you may have to ask your doctor up front how they handle the office visit/wellness check. The health care system is extremely out of whack.

Forms are another item that you can be charged additional money for, such as a depression screen, etc.
Broken Man 1999 wrote: Tue Aug 03, 2021 4:29 pm OP stated: "....I made the mistake of telling her that yes, I was having some shoulder and back pain, among other mild issues that had shown up in the last two years...."

So, to avoid paying extra you think you made a mistake telling her your issues?

How would she know if you had issues? Was she clairvoyant? A fortune teller? A psychic?

Is your health less important than your wallet?

Why even go?

Broken Man 1999
Because she basically doesn't want to be charged double.
jeam3131
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Re: Insurance coding/billing for annual preventive physical

Post by jeam3131 »

OnTrack2020 wrote: Tue Aug 03, 2021 5:31 pm Yes, you may have to ask your doctor up front how they handle the office visit/wellness check. The health care system is extremely out of whack.

Forms are another item that you can be charged additional money for, such as a depression screen, etc.
Broken Man 1999 wrote: Tue Aug 03, 2021 4:29 pm OP stated: "....I made the mistake of telling her that yes, I was having some shoulder and back pain, among other mild issues that had shown up in the last two years...."

So, to avoid paying extra you think you made a mistake telling her your issues?

How would she know if you had issues? Was she clairvoyant? A fortune teller? A psychic?

Is your health less important than your wallet?

Why even go?

Broken Man 1999
Because she basically doesn't want to be charged double.
The doctor isn't charging her double. The covered wellness visit through the ACA is only for preventative health. The doctor could easily tell the patient they aren't allowed to discuss anything else during that visit and they have to make a second appointment for the shoulder/back pain.
Last edited by jeam3131 on Tue Aug 03, 2021 5:36 pm, edited 1 time in total.
fortunefavored
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Re: Insurance coding/billing for annual preventive physical

Post by fortunefavored »

I had this happen to me too and was also enraged. There is nothing you can do except vote. Staying silent is not a great idea either, since something you mention could be important either now or in the future.

Every place in the medical world their hand is out. There's no way to avoid it other than "be really really rich so it doesn't matter" or "be over 65 and on medicare" (and the latter still has some holes, but far fewer.)

With balance billing becoming illegal going into 2022, I imagine there will be a whole new array of gotchyas introduced to claw back the lost money. I hope I don't get sick next year because I don't want to be the guinea pig.
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Re: Insurance coding/billing for annual preventive physical

Post by Misenplace »

Several posts relating to medical advice were removed.

As a reminder:

Medical Issues

Questions on medical issues are beyond the scope of the forum. If you are looking for medical information online, I suggest you start with the Medical Library Association's User's Guide to Finding and Evaluating Health Information on the Web which, in addition to providing guidance on evaluating health information, includes a list of their top recommended sites.
If you are very concerned, you can PM another user, but please don't post medical advice on the threads. It also tends to derail them.
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Re: Insurance coding/billing for annual preventive physical

Post by Misenplace »

Let me also add, if you see a post that violates forum policies, the appropriate course of action is to report it using the "!" icon in the top right of the post. We can't read every post and rely on the members to help us. Responding to it just causes additional derailment of the thread, and more work for the volunteer moderators.

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TomatoTomahto
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Re: Insurance coding/billing for annual preventive physical

Post by TomatoTomahto »

RickBoglehead wrote: Tue Aug 03, 2021 5:12 pm :?
abner kravitz wrote: Tue Aug 03, 2021 5:10 pm
TomatoTomahto wrote: Tue Aug 03, 2021 4:33 pm American healthcare is insane. Both patients and providers are to blame.

I use a concierge doctor because I don’t want to have to figure out how many billing codes can dance on the head of a pin.
How does using a concierge doctor change anything? I used a concierge doctor for a couple of years and the only thing that changed was access. The bills were the same except for the big yearly fee. Was I missing something?
No insurance, that's how.
Actually, lab tests and specialists go through insurance. My annual physical and followups also go through insurance. There are never any insurance surprises however.

What is different is that my doctor became a concierge doc because giving patients their 7 minute allotment bothered her and she considered retiring. I can spend an hour discussing my health if I feel the need.
I get the FI part but not the RE part of FIRE.
OnTrack2020
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Re: Insurance coding/billing for annual preventive physical

Post by OnTrack2020 »

jeam3131 wrote: Tue Aug 03, 2021 5:35 pm
OnTrack2020 wrote: Tue Aug 03, 2021 5:31 pm Yes, you may have to ask your doctor up front how they handle the office visit/wellness check. The health care system is extremely out of whack.

Forms are another item that you can be charged additional money for, such as a depression screen, etc.
Broken Man 1999 wrote: Tue Aug 03, 2021 4:29 pm OP stated: "....I made the mistake of telling her that yes, I was having some shoulder and back pain, among other mild issues that had shown up in the last two years...."

So, to avoid paying extra you think you made a mistake telling her your issues?

How would she know if you had issues? Was she clairvoyant? A fortune teller? A psychic?

Is your health less important than your wallet?

Why even go?

Broken Man 1999
Because she basically doesn't want to be charged double.
The doctor isn't charging her double. The covered wellness visit through the ACA is only for preventative health. The doctor could easily tell the patient they aren't allowed to discuss anything else during that visit and they have to make a second appointment for the shoulder/back pain.
But he didn't tell her--isn't that the point the OP is trying to make?? And then proceeded to charge her twice (once for office and one for preventative health during the same visit). Sorry, but it's a money grab.
Da5id
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Re: Insurance coding/billing for annual preventive physical

Post by Da5id »

OnTrack2020 wrote: Tue Aug 03, 2021 6:05 pm
jeam3131 wrote: Tue Aug 03, 2021 5:35 pm
OnTrack2020 wrote: Tue Aug 03, 2021 5:31 pm Yes, you may have to ask your doctor up front how they handle the office visit/wellness check. The health care system is extremely out of whack.

Forms are another item that you can be charged additional money for, such as a depression screen, etc.
Broken Man 1999 wrote: Tue Aug 03, 2021 4:29 pm OP stated: "....I made the mistake of telling her that yes, I was having some shoulder and back pain, among other mild issues that had shown up in the last two years...."

So, to avoid paying extra you think you made a mistake telling her your issues?

How would she know if you had issues? Was she clairvoyant? A fortune teller? A psychic?

Is your health less important than your wallet?

Why even go?

Broken Man 1999
Because she basically doesn't want to be charged double.
The doctor isn't charging her double. The covered wellness visit through the ACA is only for preventative health. The doctor could easily tell the patient they aren't allowed to discuss anything else during that visit and they have to make a second appointment for the shoulder/back pain.
But he didn't tell her--isn't that the point the OP is trying to make?? And then proceeded to charge her twice (once for office and one for preventative health during the same visit). Sorry, but it's a money grab.
The doctors office probably accepts dozens of plans with different payment schemes. Some patients have very high deductibles. Others have met their out of pocket maxes for the year and it is all "free". Some have better coverage than others. I don't expect my PCP to know or care about the details of my insurance unless I specifically bring them up. e.g. I raise the cost of a drug and ask about alternatives, the cost of a lab test and ask if every other year is good enough, etc. Not her job, and not really reasonable on my part IMO. I want her to be focused on my care, that's it.
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TSR
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Re: Insurance coding/billing for annual preventive physical

Post by TSR »

Misenplace wrote: Tue Aug 03, 2021 5:50 pm Let me also add, if you see a post that violates forum policies, the appropriate course of action is to report it using the "!" icon in the top right of the post. We can't read every post and rely on the members to help us. Responding to it just causes additional derailment of the thread, and more work for the volunteer moderators.

Moderator Misenplace
Thank you. My apologies.
Rex66
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Re: Insurance coding/billing for annual preventive physical

Post by Rex66 »

No the OP did mention it upon questioning

This is normal billing

You may not like it but it is perfectly legal and it is exactly how the rules are written.
setsail26
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Re: Insurance coding/billing for annual preventive physical

Post by setsail26 »

Let me put it in terms of another type of service. Let's say you go in for a 60,000 mile service on your car. You agree to pay $300 for this. The service advisor asks if there is anything else. You say "yeah, the engine is making this funny noise and the back hatch rattles." The mechanic then looks and tells you what is making the noises, and says the diagnosis costs $200 in addition to the $300 for the preventive service, and if you want those fixed it is another $1000. You may or may not agree with the diagnosis, and you may or may not want to pay to get it fixed, but it would be hard to argue that the extra hour of the mechanics time for diagnosis should be free. Can you go to your lawyer or accountant and say "Here's 100 bucks, deal with every concern I have about legal matters or taxes"? If not, why should you be able to do that with your doctor?
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ram
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Re: Insurance coding/billing for annual preventive physical

Post by ram »

You were billed appropriately. Your former doctor may be leaving money on the table.
Ram
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Re: Insurance coding/billing for annual preventive physical

Post by fortunefavored »

Rex66 wrote: Tue Aug 03, 2021 6:20 pm No the OP did mention it upon questioning

This is normal billing

You may not like it but it is perfectly legal and it is exactly how the rules are written.
It started right after ACA required preventative care to be included - they just said "fine, we'll charge twice." So it definitely catches out everyone at least once. Some places even charge 3 times: one more for an "initial consultation required for all new patients" which is, natch, not covered by insurance.

Read everything. Do not assume the medical industry has your health interests at heart. There's a reason healthcare is now 16% of GDP, and it isn't "great medical outcomes." - I treat them like I would a used car or life insurance salesperson.
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Re: Insurance coding/billing for annual preventive physical

Post by Rex66 »

It’s not like the physician is using a loophole. This is the intended outcome.

In fact most don’t even pick the charges. It is populated into the EMR immediately upon any positive values (again as was intended in the rule).

Only docs in small practices not using such EMRs would it be different since they then have to pick the levels. Frankly the majority would have to override to avoid this coding which is electronic documentation for management and will be discussed at contract negotiations.

I can understand why people don’t understand the rules but nothing close to insurance agent behavior is happening
VoiceOfReason
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Re: Insurance coding/billing for annual preventive physical

Post by VoiceOfReason »

I’m torn on this. The entire point of the preventative visit being covered is to encourage you to sit in front of a Dr. and then to uncover issues so that you can talk about them and have them investigated (and charged).

If you have no issues you don’t get charged. That’s what gets you to the office.

On the other hand, I will say that my wife had a similar but different experience. She visited an ENT for an issue. It was a specialist office visit. As part of the visit the ENT looked up her nose (as expected). Afterwards they billed her for an office visit and a surgical procedure. It was $300 for office visit and another $600 for the procedure. At no point did the Dr say, “I’m about to perform a surgical procedure for which you will be charged a lot”. It was ridiculous. She fought it w the office and said it was unethical for her to not be informed that looking up her nose was going to be a surgical procedure and billed that way prior to it occurring. The Dr office finally relented and agreed to remove the charge.

I agree there needs to be more transparency with medical billing.
jeam3131
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Re: Insurance coding/billing for annual preventive physical

Post by jeam3131 »

VoiceOfReason wrote: Tue Aug 03, 2021 7:38 pm I’m torn on this. The entire point of the preventative visit being covered is to encourage you to sit in front of a Dr. and then to uncover issues so that you can talk about them and have them investigated (and charged).

If you have no issues you don’t get charged. That’s what gets you to the office.

On the other hand, I will say that my wife had a similar but different experience. She visited an ENT for an issue. It was a specialist office visit. As part of the visit the ENT looked up her nose (as expected). Afterwards they billed her for an office visit and a surgical procedure. It was $300 for office visit and another $600 for the procedure. At no point did the Dr say, “I’m about to perform a surgical procedure for which you will be charged a lot”. It was ridiculous. She fought it w the office and said it was unethical for her to not be informed that looking up her nose was going to be a surgical procedure and billed that way prior to it occurring. The Dr office finally relented and agreed to remove the charge.

I agree there needs to be more transparency with medical billing.
Transparency yes, but procedures are separate from office visits. Thats how it's always been. They didn't do anything wrong and actually did you a favor by dropping the charge.

You also need to look at the insurance adjusted rate for the office visit and the procedure, not what the doctor billed. Doctors' offices often bill inflated amounts for everything but those numbers really are just place holders and have little meaning. Its all about the insurance contracted rate. I also don't know a singe insurance company that pays $300 for an office visit.
VoiceOfReason
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Re: Insurance coding/billing for annual preventive physical

Post by VoiceOfReason »

jeam3131 wrote: Tue Aug 03, 2021 7:58 pm
VoiceOfReason wrote: Tue Aug 03, 2021 7:38 pm I’m torn on this. The entire point of the preventative visit being covered is to encourage you to sit in front of a Dr. and then to uncover issues so that you can talk about them and have them investigated (and charged).

If you have no issues you don’t get charged. That’s what gets you to the office.

On the other hand, I will say that my wife had a similar but different experience. She visited an ENT for an issue. It was a specialist office visit. As part of the visit the ENT looked up her nose (as expected). Afterwards they billed her for an office visit and a surgical procedure. It was $300 for office visit and another $600 for the procedure. At no point did the Dr say, “I’m about to perform a surgical procedure for which you will be charged a lot”. It was ridiculous. She fought it w the office and said it was unethical for her to not be informed that looking up her nose was going to be a surgical procedure and billed that way prior to it occurring. The Dr office finally relented and agreed to remove the charge.

I agree there needs to be more transparency with medical billing.
Transparency yes, but procedures are separate from office visits. Thats how it's always been. They didn't do anything wrong and actually did you a favor by dropping the charge.
Disagree. She went in for an office visit, not a procedure. At no point was there an explanation from the Dr to the patient that a procedure was about to occur. It was assumed to be part of the office visit, like a PCP looking in your ears during a physical.
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celia
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Re: Insurance coding/billing for annual preventive physical

Post by celia »

We're on Medicare. One year I went to my primary care doctor as I usually do. When they called to confirm the appointment, they asked if this was for my "annual physical" where I had recently been notified by Medicare that was free (probably with a $20 incentive rebate to me, too). So I said yes. They also confirmed it when I arrived.

When the Explanation Of Benefits arrived, I saw that labs and x-rays weren't covered (but the visit was covered at 100%, instead of the usual 80%), so I called up and they said a "physical" doesn't justify labs and x-rays. There was no billing evidence of why they were even ordered. I forget how I settled it. But next time, I made my appointment for "follow-up of existing conditions". Medicare gladly pays for everything now and I no longer get "physicals". It's not like I'm trying out for a sports team or getting whole life insurance, so why request that?
:D
jeam3131
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Re: Insurance coding/billing for annual preventive physical

Post by jeam3131 »

VoiceOfReason wrote: Tue Aug 03, 2021 8:10 pm
jeam3131 wrote: Tue Aug 03, 2021 7:58 pm
VoiceOfReason wrote: Tue Aug 03, 2021 7:38 pm I’m torn on this. The entire point of the preventative visit being covered is to encourage you to sit in front of a Dr. and then to uncover issues so that you can talk about them and have them investigated (and charged).

If you have no issues you don’t get charged. That’s what gets you to the office.

On the other hand, I will say that my wife had a similar but different experience. She visited an ENT for an issue. It was a specialist office visit. As part of the visit the ENT looked up her nose (as expected). Afterwards they billed her for an office visit and a surgical procedure. It was $300 for office visit and another $600 for the procedure. At no point did the Dr say, “I’m about to perform a surgical procedure for which you will be charged a lot”. It was ridiculous. She fought it w the office and said it was unethical for her to not be informed that looking up her nose was going to be a surgical procedure and billed that way prior to it occurring. The Dr office finally relented and agreed to remove the charge.

I agree there needs to be more transparency with medical billing.
Transparency yes, but procedures are separate from office visits. Thats how it's always been. They didn't do anything wrong and actually did you a favor by dropping the charge.
Disagree. She went in for an office visit, not a procedure. At no point was there an explanation from the Dr to the patient that a procedure was about to occur. It was assumed to be part of the office visit, like a PCP looking in your ears during a physical.
You assumed wrong. They are separate in every office for every specialty. That is how healthcare in the United States works. These are CPT codes that have been put forth by our government, not the office you went to.

I'd also be willing to bet the intake paper work they had you sign also stated this. Procedures and office visits are billed separately. It actually took a lot of training for that ENT to use that scope, and they are also assuming liability when doing so.
Last edited by jeam3131 on Tue Aug 03, 2021 8:20 pm, edited 2 times in total.
VoiceOfReason
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Re: Insurance coding/billing for annual preventive physical

Post by VoiceOfReason »

jeam3131 wrote: Tue Aug 03, 2021 8:15 pm
VoiceOfReason wrote: Tue Aug 03, 2021 8:10 pm
jeam3131 wrote: Tue Aug 03, 2021 7:58 pm
VoiceOfReason wrote: Tue Aug 03, 2021 7:38 pm I’m torn on this. The entire point of the preventative visit being covered is to encourage you to sit in front of a Dr. and then to uncover issues so that you can talk about them and have them investigated (and charged).

If you have no issues you don’t get charged. That’s what gets you to the office.

On the other hand, I will say that my wife had a similar but different experience. She visited an ENT for an issue. It was a specialist office visit. As part of the visit the ENT looked up her nose (as expected). Afterwards they billed her for an office visit and a surgical procedure. It was $300 for office visit and another $600 for the procedure. At no point did the Dr say, “I’m about to perform a surgical procedure for which you will be charged a lot”. It was ridiculous. She fought it w the office and said it was unethical for her to not be informed that looking up her nose was going to be a surgical procedure and billed that way prior to it occurring. The Dr office finally relented and agreed to remove the charge.

I agree there needs to be more transparency with medical billing.
Transparency yes, but procedures are separate from office visits. Thats how it's always been. They didn't do anything wrong and actually did you a favor by dropping the charge.
Disagree. She went in for an office visit, not a procedure. At no point was there an explanation from the Dr to the patient that a procedure was about to occur. It was assumed to be part of the office visit, like a PCP looking in your ears during a physical.
You assumed wrong. They are separate in every office for every specialty. That is how healthcare in the United States works. I'd also be willing to bet the intake paper work they had you sign also stated this.
That’s exactly what the office Mgr said. And our response was never to dispute that I’m sure it is in there on some ppw that was shoved in her face minutes before her appointment. That does t change the fact that it’s unethical and wrong. There is absolutely no excuse for why tge Dr wouldn’t disclose a PROCEDURE was about to occur during an office visit.
jeam3131
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Re: Insurance coding/billing for annual preventive physical

Post by jeam3131 »

VoiceOfReason wrote: Tue Aug 03, 2021 8:19 pm
jeam3131 wrote: Tue Aug 03, 2021 8:15 pm
VoiceOfReason wrote: Tue Aug 03, 2021 8:10 pm
jeam3131 wrote: Tue Aug 03, 2021 7:58 pm
VoiceOfReason wrote: Tue Aug 03, 2021 7:38 pm I’m torn on this. The entire point of the preventative visit being covered is to encourage you to sit in front of a Dr. and then to uncover issues so that you can talk about them and have them investigated (and charged).

If you have no issues you don’t get charged. That’s what gets you to the office.

On the other hand, I will say that my wife had a similar but different experience. She visited an ENT for an issue. It was a specialist office visit. As part of the visit the ENT looked up her nose (as expected). Afterwards they billed her for an office visit and a surgical procedure. It was $300 for office visit and another $600 for the procedure. At no point did the Dr say, “I’m about to perform a surgical procedure for which you will be charged a lot”. It was ridiculous. She fought it w the office and said it was unethical for her to not be informed that looking up her nose was going to be a surgical procedure and billed that way prior to it occurring. The Dr office finally relented and agreed to remove the charge.

I agree there needs to be more transparency with medical billing.
Transparency yes, but procedures are separate from office visits. Thats how it's always been. They didn't do anything wrong and actually did you a favor by dropping the charge.
Disagree. She went in for an office visit, not a procedure. At no point was there an explanation from the Dr to the patient that a procedure was about to occur. It was assumed to be part of the office visit, like a PCP looking in your ears during a physical.
You assumed wrong. They are separate in every office for every specialty. That is how healthcare in the United States works. I'd also be willing to bet the intake paper work they had you sign also stated this.
That’s exactly what the office Mgr said. And our response was never to dispute that I’m sure it is in there on some ppw that was shoved in her face minutes before her appointment. That does t change the fact that it’s unethical and wrong. There is absolutely no excuse for why tge Dr wouldn’t disclose a PROCEDURE was about to occur during an office visit.
You're really missing the point and one of the main themes of this whole thread. When you go to see a doctor, everything is not going to be bundled under one charge. Thats not reasonable and the reimbursements rates for that alone wouldn't sustain a medical practice. Believe it or not, running a medical practice is really expensive. In many of the larger healthcare groups, offices that only provide services that fall under one charge/visit often run at a loss.

If you go in and multiple things are done or addressed, you will be billed for each thing separately. The doctor is not going to stop your visit every time and say you will be billed extra for this. That interferes with their ability to actually provide the care that is needed. Many patients would just say no, don't do that etc. That would open another can of worms with missed diagnoses and liability etc.

It's your job to understand your health insurance benefits, your insurance coverage, and also to read paperwork that you sign. Would more transparency be nice? Of course. But the billing and coding is governed by rules set by the government and its not reasonable to expect a busy doctors office to stop every patient and inform them every time a new procedure code or office visit code was being generated. Its logistically impossible and most patients would not even understand the first word of it. Most patients don't ever understand what a deductible is
Last edited by jeam3131 on Tue Aug 03, 2021 8:54 pm, edited 1 time in total.
shess
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Re: Insurance coding/billing for annual preventive physical

Post by shess »

setsail26 wrote: Tue Aug 03, 2021 6:39 pm Let me put it in terms of another type of service. Let's say you go in for a 60,000 mile service on your car. You agree to pay $300 for this. The service advisor asks if there is anything else. You say "yeah, the engine is making this funny noise and the back hatch rattles." The mechanic then looks and tells you what is making the noises, and says the diagnosis costs $200 in addition to the $300 for the preventive service, and if you want those fixed it is another $1000. You may or may not agree with the diagnosis, and you may or may not want to pay to get it fixed, but it would be hard to argue that the extra hour of the mechanics time for diagnosis should be free. Can you go to your lawyer or accountant and say "Here's 100 bucks, deal with every concern I have about legal matters or taxes"? If not, why should you be able to do that with your doctor?
Instead, let’s say you went for a car diagnostic. First, the mechanic looks at the car while you remain silent. Maybe they find things, maybe they don’t. Then they ask “How is the vehicle working for you?”, and you respond that it makes a weird noise when braking.

Isn’t the entire point of a wellness visit to figure out if you have any issues which need addressing? If so, isn’t the richest source of information about your health likely to be YOU?

This isn’t really a “gotcha!” case, where you sneak in and dump thousands of dollars of unreimbursed costs on them. There should be a modest amount of diagnosis built into a wellness visit to cover chronic issues which my be minor, but which aren’t annoying enough to the patient to warrant a full visit. As I get older, I notice more and more issues where I’m like “Is this actually minor, or am I channeling my grandma and refusing to see someone because I don’t want to bother them?”
jeam3131
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Re: Insurance coding/billing for annual preventive physical

Post by jeam3131 »

shess wrote: Tue Aug 03, 2021 8:45 pm
setsail26 wrote: Tue Aug 03, 2021 6:39 pm Let me put it in terms of another type of service. Let's say you go in for a 60,000 mile service on your car. You agree to pay $300 for this. The service advisor asks if there is anything else. You say "yeah, the engine is making this funny noise and the back hatch rattles." The mechanic then looks and tells you what is making the noises, and says the diagnosis costs $200 in addition to the $300 for the preventive service, and if you want those fixed it is another $1000. You may or may not agree with the diagnosis, and you may or may not want to pay to get it fixed, but it would be hard to argue that the extra hour of the mechanics time for diagnosis should be free. Can you go to your lawyer or accountant and say "Here's 100 bucks, deal with every concern I have about legal matters or taxes"? If not, why should you be able to do that with your doctor?
Instead, let’s say you went for a car diagnostic. First, the mechanic looks at the car while you remain silent. Maybe they find things, maybe they don’t. Then they ask “How is the vehicle working for you?”, and you respond that it makes a weird noise when braking.

Isn’t the entire point of a wellness visit to figure out if you have any issues which need addressing? If so, isn’t the richest source of information about your health likely to be YOU?

This isn’t really a “gotcha!” case, where you sneak in and dump thousands of dollars of unreimbursed costs on them. There should be a modest amount of diagnosis built into a wellness visit to cover chronic issues which my be minor, but which aren’t annoying enough to the patient to warrant a full visit. As I get older, I notice more and more issues where I’m like “Is this actually minor, or am I channeling my grandma and refusing to see someone because I don’t want to bother them?”
The preventative health portion does have clearly defined things built into it including diet, exercise, BP management, cancer screening etc. But its not fair to bundle in all your other issues into that visit that warrant extra time from the doctor and expect it to be "free". If all you discuss is your general health, then it will all fall under preventative screening. If you start bringing up your abdominal pain or constipation etc, then its outside of the scope of that. Preventative screening really doesn't cover that much that can't be checked off on a questionnaire. There seems to be a misconception that this preventative screening visit is all inclusive. In fact, its actually very very limited.
Rex66
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Re: Insurance coding/billing for annual preventive physical

Post by Rex66 »

My least favorite holidays are thanksgiving and Christmas.

Reason being is the end of the year comes with the most neglected cancers. Every year people delay coming in bc they haven’t met their deductible. At thanksgiving or Christmas. Son or daughter comes home and says what the heck is going on. They call the following day panicked for an urgent appointment. Sometimes I can’t fix the problem at this point. It’s difficult for the family and it is hard on me mentally as well.

There are actually indications for every procedure. Those indications are necessary to get paid for doing it. You can’t just do it for more money. Your wife was told she was having a scope, she just didn’t understand that entails additional costs. If they had found a life saving cancer, you wouldn’t have complained.
toofache32
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Re: Insurance coding/billing for annual preventive physical

Post by toofache32 »

This is an INSURANCE issue, not a doctor issue. This is YOUR insurance (not the doctors) so you must take it up with your insurance company. Most people confuse this visit for a yearly "freebie" of getting every complaint dealt with possible and don't read the insurance guidelines of what this visit covers. Then they get mad at the doctor because it doesn't cover shoulder pain. Maybe I should start getting angry at the airline pilot when my flight is delayed.
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Cubicle
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Re: Insurance coding/billing for annual preventive physical

Post by Cubicle »

I blame insurance companies far more than patients & doctors. They set the payments rates & what they will pay for. They collect the money from patients & the government, then decide how it gets doled out.

And personal injury claims. Insane to say the least.

And I'm glad someone else mentioned... Liability. If that ENT looked up a nose & saw something cancerous, but then realized it's not included in the free package, should they bite their tongue?

By even mentioning you have a headache, the doctor is liable if you crash your car on the way home because you had a brain bleed. Shoulder pain? Torn ligament, frozen shoulder, lifelong disability because it wasn't dealt with before you did landscaping when at home. Rash? Allergic reaction, infection, necrotizing fasciitis. He/she has malpractice insurance to pay for (see personal injury claims above) & every single liability should contribute to the malpractice insurance premium.
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MM1130
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Re: Insurance coding/billing for annual preventive physical

Post by MM1130 »

I had a visit coded as a school exam ($130) once because they signed a form rather than an annual wellness physical (free) which is what I asked for. 0 issues, 0 history, 0 diagnostics ordered. There absolutely needs to be more transparency when it comes to medical visits, what is being ordered and cost, etc.

It’s not that hard to start the appointment with “feel free to discuss any issues you are currently having, but you will be charged as a sick visit for anything beyond preventative care and renewal of your current medications.” I also would appreciate the medical office telling me in advance what I can expect for costs (and YES, if a provider sees your age and history they will have a good idea of what they plan to order in advance for labs). Even just a “hey, I’m going to order a TSH based on your history. Don’t forget you can do this through direct access testing for a lower rate and they’ll send me the results” or “You are due to get a pap today and since you’re sexually actively we recommend STI testing— they might not be covered by insurance. Would you like to proceed with testing?” would be SO appreciated rather than just doing.
VoiceOfReason
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Re: Insurance coding/billing for annual preventive physical

Post by VoiceOfReason »

MM1130 wrote: Tue Aug 03, 2021 11:59 pm You are due to get a pap today and since you’re sexually actively we recommend STI testing— they might not be covered by insurance. Would you like to proceed with testing?” would be SO appreciated rather than just doing.
Exactly. It's so inconsistent.

Myself, wife and kids have had minor surgeries performed at outpatient / hospital facilities. At almost every one of these, during the planning phase where you meet with the Dr, review the need for the surgery, etc, one huge component is the office mgr reviewing with you in great detail your expected costs for this procedure. (Because it is usually $ a thousand or more). They pre-submit to your insurance, review with you that you will get a bill from the hospital facility and the anesthesiologist. In some instances I've been asked to sign documentation that I've been shown this cost ahead of time and I agree to pay it after the procedure. Some have even offered me 10% discounts to pre-pay it. (which I've done every time it's been offered). I've never been more prepared to know exactly what my costs will be than for a planned surgery.

Yet somehow a planned office visit there can't be any transparency....right.
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Re: Insurance coding/billing for annual preventive physical

Post by oldcomputerguy »

A post suggesting that one should never go for a preventative care appointment was removed as medical avice. This thread has derailed into a general complaint over medical billing procedures, and so is locked (topic exhausted). See: Locked Topics
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