Annual exams vs. annual wellness visits

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 benefitsand 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!

Sláinte,

Frugal Nurse

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Comments

Annual exams vs. annual wellness visits — 7 Comments

  1. Despite the fact that insurance pays, why even attempt to have a PCP relationship when it is nothing but a q&a. Since when do doctors let alone their nurse practitioners feel it is so important to ask if you wear your seat belt, have smoke detectors or own guns rather than how have you been feeling? What was shocking is that simple maintenance drugs are only issued for 6 months and then another appt is necessary.

    I’m so glad that I opted to developers my healthcare relationships with specialists. Same price, longer appt but you don’t get the feeling that you are a revenue stream.

  2. I have an ARNP as my PCP. This is the first time I have had the office call me twice to schedule my “wellness exam”. It will not be w/my PCP, it will be with the Medical Assistant. Is this typical? Thanks! Dg

    • Hi Daphne, thanks for your comment. Different health organizations have different policies, but yes, it is becoming more typical that lower-level providers cover the wellness visits. Because these exams are basically about plugging people into age and gender appropriate screening tests, it’s not considered worth the physician’s (or ARNP apparently) time. Also, the insurance company reimburses the same, which is another disincentive to waste a physician’s time.

      I don’t like this trend. I think too many unnecessary screening tests are being done and we should be able to have an informed discussion with our chosen health care provider about which tests we really need–a need based on more than just our age and gender. I don’t believe a lower-level provider, like a medical assistant, will have the education or experience to do this.

      You could ask to see your ARNP for the wellness visit instead of the MA, but you might then be charged for an office visit. But it doesn’t hurt to ask. Good luck! FN

  3. Is there any data to support the new regulations? Would it not be more expensive and inefficient to revisit a doctor multiple times to mention different concerns? I would think that the paperwork alone would be prohibitively expensive. The one visit, one problem rule seems to be a frustrating barrier to getting decent care from a doctor. Most people are challenged enough to get to a doctor once, much less multiple times within a year.

    • Hi Nathan, thanks for the comment. Well, I think you hit on the head one of the many reasons health care is so expensive–the administrative costs are massive. One of the driving factors behind the one visit, one problem rule, I believe, is electronic health and billing records. Reimbursement is maximized when one diagnosis code (rather than several) is paired with one procedure code. I agree with you that it’s not an efficient use of time or money, at least for the patient! Cheers, FN

  4. You have accurately described many people’s situation. My doctor and clinic have changed the name to “wellness visits,” but I’m still receiving the same annual exam, during which I bring up other stuff I’ve been saving up to tell the doctor about to see if he thinks it is important for some reason. There are more questions, as you mention, almost all of which are irrelevant to me I’m happy to say.

    My annual wellness visit is coming up soon. I keep wondering every year whether I will experience the change to what you have described. I know people who have. Others have posted pictures on social media of signs in doctors’ offices announcing the institution of a one visit, one problem rule.

    • Hi Ray, always nice to hear from you! If you have a long-standing relationship with a doctor, it’s more likely he or she will spend more time with you. The patient-doctor relationship really makes a difference. Unfortunately, more of us (myself included) have had to change our doctors because of our insurance networks, and our new doctors are less likely to take the extra time out of their already crazy clinical schedules.

      There has also been a lot of confusion among both physicians and patients about what these “wellness” visits entail. More medical practices are standardizing these visits to only meet the minimum federal requirements of data gathering and screening guidelines. Under it’s coding definition, Medicare’s Annual Wellness Visit or AWV can take no longer than 20 minutes, although I’m not really sure how they can police that.

      Have a healthy 2016! FN