Happy New (Calendar) Year!
It’s the start of a new year or, in health insurance lingo, the start of a new calendar year deductible. I’m reposting this from last January, because this month is the best time to start trying to schedule that annual exam or annual wellness visit (it could take weeks, after all, to get an appointment!).
I usually advise people to get any screening tests or annual exams done early in the year, just in case an abnormality is found and more testing/treatment is necessary.
Especially with the current trend towards enormous deductibles (up to $14,300 for families in 2017), you don’t want to pay for a lot of expensive health care in December, meet your deductible, and then immediately start your deductible all over again in January.
The “free” annual exam was one of the selling points of the Affordable Care Act (ACA), but the term “there’s no such thing as a free lunch” applies here. Insurance companies just raise premiums and co-pays to cover the mandated preventive care coverage.
Not all annual exams are equal
Before you schedule this so-called free exam, there are a few things you should know.
Prior to the ACA, I could schedule an annual physical with my doctor and be given a full one-hour time slot. She would do a thorough exam that included listening to my heart and lungs, looking in my ears, eyes and nose, checking my skin for unusual moles or rashes, testing my reflexes, examining my breasts and armpits for lumps, and doing a pelvic exam and Pap smear.
We would chat about what was happening in my life—how much was I exercising, how was my diet, were my relationships OK, was I sleeping OK, was I stressing out about anything, etc. Over the year, I made a list of several little complaints to talk to her about, because none of them warranted a special office visit.
The annual exam cost more than a typical visit, but I felt it was a good value, and I always left that physical feeling cared for and comfortable with my patient-doctor relationship.
Not any more.
Now the free, ACA-mandated preventive care or wellness visit (aka Annual Wellness Visit in Medicare plans) is a short (15 minutes, if you’re lucky), computer-generated template with the primary purpose of having you answer probably-not-relevant health questions (“meaningful use”, i.e. big data) and get scheduled for a variety of screening tests.
And the usefulness of many of these tests—mammograms, DEXA scans, PSAs, to name a few—is debatable.
If you deviate from this scripted visit, such as asking your doctor to look at a funny mole or mention that you haven’t been sleeping well, you risk being billed for a regular office visit or being asked to hold that thought and schedule another appointment. (Not nice if you’ve already waited weeks for this appointment!)
Related story from US News & World Report: When a free check-up isn’t really free
Doctors have a new rule: One problem, one visit.
To be fair, many doctors had this rule before Obamacare, but increased government regulation and bureaucratic management have made it worse.
Many health professionals, myself included, question whether these annual exams are of any benefit. Do they really result in healthier patients, or just generate more income for the health care industry?
“This specialized visit hasn’t proven anything in terms of staying healthful,” says Dr. Ateev Mehrotra, an associate professor of health care policy and medicine at Harvard Medical School. Mehrotra co-wrote an editorial in the most recent edition of the New England Journal of Medicine calling the physical outdated. He points out that physicals for healthy individuals can result in a battery of unnecessary tests and visits that aren’t effective in preventing disease.
Know what’s covered, and what isn’t
But if you do want an annual exam, ask the receptionist if the doctor makes a difference between a wellness visit and a more thorough head-to-toe exam. Ask how much time is allotted for each. A longer exam will probably require you to pay a copay or the full cost of the visit, depending on your insurance coverage.
If you want to take advantage of the free annual wellness visit, be very specific when you schedule it with your doctor’s office. They will need to use the correct procedure (CPT) code and diagnosis (ICD-10) code to ensure you are not charged.
The diagnosis code has to be a well-woman or well-adult code. If you bring up another complaint, such as insomnia, and that diagnosis is used instead, you will be billed for a regular office visit, or an office visit in addition to the wellness exam.
If you think you have been billed in error, first call your doctor’s billing office and find out what codes were used. Explain the visit was supposed to be a wellness visit. If the wrong code was used, they will probably ask you to call your doctor and have him or her resubmit the charges with the correct codes to your insurance company.
Also, you should be aware that not all screening tests ordered by your physician will necessarily be covered by your insurance. I know from personal experience that a vitamin D level is not covered, nor is a DEXA scan for bone density before the age of 65.
So before you go to your appointment, talk to your insurance company and ask which preventive tests are covered in full. Bring that list with you to your exam. If your doctor wants to order something not on the list, be sure to ask why it is necessary.
You can also check out Healthcare.gov’s list of free preventive care benefits, and review some of the evidence-based healthcare websites listed on my Resources page.
And again, if an annual exam is something you want, schedule it early in the year to potentially get the most benefit from your health insurance!