r/HealthInsurance • u/Weak-Internet5938 • Dec 11 '24
Claims/Providers Is this reasonable?
I went for my first annual physical exam, which my insurance said would be 100% covered. I specifically asked for a physical, but I ended up with a $400 bill from the clinic and another $200 from the lab. When I called my insurance, they said some blood tests and parts of the visit weren’t covered under preventive care. The clinic claimed that discussing acne and thyroid issues was outside preventive care, but those topics were raised by the doctor, not me. The doctor noticed my acne and suggested treatment, then commented on my thyroid and recommended an X-ray—yet I’m being charged $400 for a few seconds of conversation. Is this normal, or does it feel like a scam to anyone else?
17
u/Msgatorslayerr Dec 11 '24
Anything outside of basic blood pressure check, temp, listening to the heart, going over medical history with the nurse, and talking about meds/refills is considered outside of the scope of a regular, covered, preventive care yearly checkup. It's crazy what health care has become.
3
u/Tech_Rhetoric_X Dec 11 '24
Following up on a thyroid issue is essential. It must be evaluated if the doctor found something like a goiter or some mass. The reason for having yearly physicals is to catch potential problems early. Sometimes, that means paying to discover what is outside the norm.
4
u/dumb_username_69 Dec 11 '24
I commented on a very similar situation the other day, too lazy to retype :)
1
u/Weak-Internet5938 Dec 11 '24
Thank you for sharing. This is so frustrating that I don’t even know how can I prevent it from happening again. Should I just covered my ear when doctors mentioned thing, that just sound ridiculous. Feel like a trap from the insurance and clinic
2
u/BostonDogMom Dec 11 '24
I might look for a doctor that prioritizes saving you money and keeping you healthy.
A good doctor would say, I can look into your thyroid issues with you but if I order tests it will cost you hundreds of dollars. Call me when you are ready to pursue this.
A community health center or the outpatient clinic of a safety net hospital is usually really good at this.
3
u/dumb_username_69 Dec 11 '24
I totally agree. I don’t really know who to “blame”. Ultimately, the dr office bills the insurance company the codes based on what services were received. The insurance company didn’t make them up, they just paid according to what was billed. And I’d like to think that when the doctor is typing up their notes and such afterwards that they’re unaware of the financial burden they’re adding to their patients. I hope that it’s just a crack in the system and not intentional :(
5
u/positivelycat Dec 11 '24
Oh trust me many don't. They don't agree but it is correct and to follow correct billing and insurance coverage guidelines it has to be done. The system just sucks.
I have given up on getting a " physical " 100% covered
2
u/Emotional_Blood_4040 Dec 11 '24
You just made Quote of the Year (my year anyway) with that you would like to think ...the "...doctors are unaware of the financial burden they're adding to their patients." 🫡
3
u/dumb_username_69 Dec 11 '24
It’s just the scenario I play in my mind on repeat so I don’t lose it over the endless cycle that is American for-profit health insurance lol
4
u/konqueror321 Dec 11 '24
Yes it is normal, and of course it is a scam, but fully legal. It is normal to have prices obscured in American medicine - it is unusual to actually know what some service or test will truly cost in advance.
The ACA mandated that certain preventive care interventions be offered to patients without copays or coinsurance - the insurance company pays for these items completely. But many docs understand the rules about what is 'preventive' and if any non-preventive issues come up, they will submit additional 'evaluation and management' codes that generate additional insurance payments, that include copayments or coinsurance and satisfying the annual deductible -- ie it can cost you (especially if you have not yet paid your full annual deductible).
Is this fair? Technically it follows the written rules. But most patients do not understand how all of this works and believe that they can discuss non-preventive issues with the Doc during a preventive visit and escape copayments etc -- some docs may let this slip, some will ensure you get billed.
The issue of $400 for a few seconds of conversation is a valid concern. Medical coding and billing is an art unto itself. Much depends on exactly what is documented in the written progress note for the appointment - there are specific criteria for what is 'necessary' for billing for various levels of service, and sometimes the time spent on the issue is also determinative. To find out if your doc 'upcoded', or billed at a higher reimbursement rate that was justified by the written note would probably require that the note be reviewed by a knowledgeable medical coder - if that were done, and the document did not support the billing level you were charged, you could complain to the Doc or your insurance -- how that would shake out is unpredictable.
Your insurance should be able to tell you what 'codes' were submitted with the claim (preventive codes, diagnostic codes, and procedural/treatment codes). Knowing these would allow you to 'look up' the codes on the internet and perhaps learn what sort of work the Doc should have done (and documented) for that billing code. Is this worth your time? Only you know!
0
u/bevespi Dec 11 '24
This is why I don’t have my nurse schedule annual exams routinely. You pay a copay and talk about whatever you want. 🤷🏻♂️
-1
u/jumpythecat Dec 11 '24
It's somehow a legal scam. Once additional tests are done it becomes a new diagnosis. It's the problem with reimbursement through fee-based codes. There's very little chance of fighting it, but you can certainly try. Just be aware for next year. But if they found a thyroid condition, then anything regarding that condition will be diagnostic and not preventative. Try to think of it as they saved you a trip to come back again.
1
u/Honest-Ticket-9198 Dec 11 '24
I just had basic physical required and never paid before. UHC, and this time it was 18.00 extra.
Then, sine I had breast cancer I have breast exams every 6 months. At Dr orders. This time I got a bill afterwards. My premiums went up, coverage went down.
0
u/Pale_Natural9272 Dec 11 '24
Ask your doctors office to recode it as a preventative wellness visit.
-3
u/jaybirdforreal Dec 11 '24
Preventive care is not covered. It doesn't matter what they say. You will end up with surprise bills.
2
u/dumb_username_69 Dec 11 '24
IMO this is too generic of a statement to share with people who barely understand health insurance. Most ACA compliant plans do cover preventative care, the problem is that the legal definition of preventative care is soooo specific which will often lead to unexpected situations like this. Agree it feels misleading at times!
-2
u/Weak-Internet5938 Dec 11 '24
Is there anything I can do about this charge?
2
u/Initial-Woodpecker39 Dec 11 '24
Call your doctor’s office to ask that the visit be resubmitted with routine physical codes. Your insurance company can’t legally change the codes the office submitted to get them to pay as preventive.
2
u/positivelycat Dec 11 '24
However billing also can not legally change the codes if chart documentation supports something more then a physical happened. They can check the records to make sure the records match but If they do match no change can be made
-1
u/CindysandJuliesMom Dec 11 '24
I just go to one of those minute clinic places. Not as accurate as a blood draw but I pay nothing for the visit for my annual exam.
To go to a doctor, since I don't have one, would mean paying for an initial visit then scheduling my annual checkup. Even more stupid I was able to get my mammogram for free at a mobile clinic but getting a pap smear requires a referral from my PCP which means I would have to pay for an office visit.
0
u/LowParticular8153 Dec 11 '24
Discussing acne, actual medical illness is not preventative.
Urinalysis, some of blood panel is.
•
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