Medical Billing Question - Double Billed for Preventative Visit?

[DisneylandFreak2013]

I scheduled an annual exam. Preventative visits are 100% covered under my insurance, allegedly. I showed up and completed a well woman exam, was scheduled for bloodwork, and also brought up that I would like to try medication to help manage my anxiety. When I checked out, they said I did not owe anything because it was a preventative visit.

I just received a bill for not only the wellness visit, but also an office visit. I can kind of understand them charging me an office visit because I brought up anxiety, but why am I also now paying for a wellness visit? So, I now owe $350 for a 30 minute appointment ($225 for wellness exam, $125 for office visit....I got a discount on both for being in-network). I am going to call both my insurance and the doctor's office tomorrow but want to see if anyone has any experience with this. With their billing, I would have been better off staying silent at my wellness exam then scheduling another appointment to get prescribed anxiety meds.

Getting billed for double may make sense, but having to pay for both does not. Shouldn't wellness be covered and I only should owe $125?

 

[bluecruiser]

My insurance covers one annual wellness exam per year at no cost to me. The doctor let me know if I want to discuss anything else at that visit that a regular office visit will be billed and I'll owe a copay. But the wellness part is no cost to me.

Sounds like your insurance is the same and the office should NOT have billed you for the wellness exam. Hopefully you can get it straightened out.

 

[disneychrista]

What does the explanation of benefits statement say your owe? I wouldn’t pay anything until I reviewed the EOB.

My first thought was that maybe being up the anxiety invalidated the well exam but sounds like they want to double dip, which doesn’t sound right at all. They either charge for the office visit or charge for the well visit. Not both.

How much would it he visits be without insurance? That seems crazy expensive to me. I pay $20 for an office visit. Zero for preventive. I have never had to pay for my annual physical nor my well woman exam even when other things were discussed or discovered

 

[luvthatduke]

It seems like it's always a coding mistake when these things happen.
I would call your doctors office first and explain it.
They will likely tell you to wait until they get back to you before
calling your insurance.
My mom went through something simliar.

 

[nw6675]

They can be billed together:

https://www.ama-assn.org/practice-m...ll-both-preventive-and-em-services-same-visit

EM are office visits for those not familiar.

But to OPs question, definitely questionable that your insurance didn't pay the wellness.

 

[CynBeth]

I do medical billing and during a wellness exam if anything medical is brought up there could be 2 procedure codes for the wellness portion it would be a preventative medicine procedure code and a procedure code for an office visit. With the office visit code there can be patient responsibility for copay, coinsurance, or deductible. But this sounds like you are being charged way more than that and there could be an issue with the coding. For the wellness visit code there is a certain routine diagnosis code that gets used and I wonder if the office used medical diagnosis codes on it instead or along with it and should only be the routine dx code. Also, on the office visit procedure code if the office used for anxiety a mental health diagnoses code and no other medical diagnosis code some insurances do not cover mental health or if they had other diagnosis codes with it they could have put that as the primary diagnosis code and it would need to be listed as the last one. Or they could have also used the routine diagnosis code on the office visit which can cause issues. On the bill if there is a phone number for customer service or billing I would call there so this can be looked at. A lot of customer service is now outsourced I know the group we do billing for is and I hate to say it they are awful and do not understand a lot of things so if you can tell when someone answers that they are offshore I would ask if there is anyone onshore might have to say in the US or a supervisor you can talk to it is a complicated issue. Good luck! Please let us know what happens.

 

[DisneyOma]

Why in the world is it a chargeable event if one brings up an issue during a wellness checkup? Isn't that what the doctor is asking - if there are any issues about health? Ugh, the United States is whacked. Health care shouldn't be a profitable venture.

 

[DisneylandFreak2013]

What does the explanation of benefits statement say your owe? I wouldn’t pay anything until I reviewed the EOB.

My first thought was that maybe being up the anxiety invalidated the well exam but sounds like they want to double dip, which doesn’t sound right at all. They either charge for the office visit or charge for the well visit. Not both.

How much would it he visits be without insurance? That seems crazy expensive to me. I pay $20 for an office visit. Zero for preventive. I have never had to pay for my annual physical nor my well woman exam even when other things were discussed or discovered

I was wondering the same, if I was being charged a higher rate because I have insurance.

I have a HDHP through my employer, which in the long run is supposed to save money because premiums are only $40/month and we get a match on our HSA but insurance does not kick in until I reach the deductible of $1,500.

 

[DisneylandFreak2013]

Thanks, everyone. I am going to call here in a bit when the office opens and hope to get someone to look at it.

 

[Moliphino]

I just had a weird insurance experience in the other direction. I got a refund check for $45 related to a recent eye exam and I have no idea why. The eye exam was covered by my Cigna Vision plan. I only paid the $40 for the contact lens fitting, which I know isn't covered. Cigna seems to think I paid $145 and should only be responsible for $100 myself. I didn't pay $145 for anything and didn't submit a claim. I don't see anything about a $145 claim when I log into my account. It's a mystery.

 

[mom2rtk]

Why in the world is it a chargeable event if one brings up an issue during a wellness checkup? Isn't that what the doctor is asking - if there are any issues about health? Ugh, the United States is whacked. Health care shouldn't be a profitable venture.

That seems to be more common these days. My doctor's office has a notice up now.

I think the issue is that everyone has these high dollar deductible plans so are paying fully out of pocket until they meet that deductible so are trying to get all of their care done in that one "free" visit.

 

[slo]

Thanks, everyone. I am going to call here in a bit when the office opens and hope to get someone to look at it.

Good luck - Let us know how it went.
I hope someone just coded something wrong and it can be fixed and resubmitted.

 

[focusondisney]

Why in the world is it a chargeable event if one brings up an issue during a wellness checkup? Isn't that what the doctor is asking - if there are any issues about health? Ugh, the United States is whacked. Health care shouldn't be a profitable venture.

My first thoughts also. The doctor should be reviewing everything about your health with you at an annual wellness visit. There are even questions about depression & anxiety asked on the pre visit screening forms. Anxiety could affect your physical health in a lot of ways so of course it should be addressed as well.

 

[bluecruiser]

Edited to add - I see @eksmama01 already posted the link. Leaving my post here for the excerpt from the article.


Found this on the AMA (American Medical Association) website: Can physicians bill for both preventive and E/M services in the same visit?

There's much more detail at the link, but here's a short excerpt:

"Physicians are not prohibited from coding and billing for both preventive and problem-focused E/M services when they are performed during the same appointment. The significance of the problem addressed and the amount of time and medical decision-making required help determine how the services are most appropriately billed. It is important to accurately and completely document all medically appropriate and necessary care performed during a patient encounter, and to bill for what is documented. Many physicians, usually motivated by a desire to avoid audits, tend to under-code for the work they have performed, resulting in significant amounts of uncompensated care."

How insurance pays for such a bill (and what the patient owes) is a different story. As I said, in my experience I owed just the office visit copay when this situation occurred. My insurance is a BCBS PPO in Pennsylvania.

 

[DisneyOma]

That seems to be more common these days. My doctor's office has a notice up now.

I think the issue is that everyone has these high dollar deductible plans so are paying fully out of pocket until they meet that deductible so are trying to get all of their care done in that one "free" visit.

So what if they are trying to get it done during their prepaid visit? That's what it is for - what else are they doing? They are screening for issues, I hope. If they don't do that, what's the point? It's a screwed up country that makes it expensive to get health issues taken care of early!

 

[mom2rtk]

So what if they are trying to get it done during their prepaid visit? That's what it is for - what else are they doing? They are screening for issues, I hope. If they don't do that, what's the point? It's a screwed up country that makes it expensive to get health issues taken care of early!

Well, they only have so much time allocated for an annual check up. Bringing up lots of extra issues pushes the entire schedule off. I assume the same people trying to cram a year's medical care into one visit are the same ones who would throw a fit if they are running behind and they have to wait.

Don't mistake that for my defense of the entire system though. This bit where yeah we have everyone insured, but they all have $6K deductibles is ridiculous. That's not coverage. That's done to mark it off a political check list.

Just like with college debt, they have done nothing in this system to address the COST issue. They have made the problem worse, not better.

 

[sk!mom]

I guess I love my doc more now. Last Spring during my well visit, she asked about all over health, current on dental etc…as she always does.

I mentioned that I had building anxiety related to extensive dental work and implants. We discussed medication and she prescribed something for me to take before each dental appointment. It was not coded or charged outside of the well check.

I wasn’t waiting to bring it up for free. I hadn’t considered meds as I’ve never had anxiety outside of medical appointments and I’ve always managed. She brought it up and I answered truthfully.

 

[Luv Bunnies]

Several years ago, I went in for my annual with my OB/GYN. The medical assistant took my blood pressure, etc. and confirmed that I was there for my annual. I said yes, and there was also something more specific I wanted to ask the doctor about. The assistant was very direct in saying, "You are here ONLY for your annual. Any other issues would have to be addressed in a separate appointment. You are not allowed to discuss that with the doctor at this appointment." I thought that was crazy! Isn't an annual check-up a time to discuss how you've been and if there's anything that needs to be addressed? When the doctor came in, she asked how I was doing so I brought up my question. She answered it readily and completely. She never said I would need a separate appointment, and my appointment wasn't billed any differently. If my issue required a longer exam or extra testing, etc., I would fully expect to have to schedule a new appointment. But I thought that was something for the doctor to decide. I didn't like being "scolded" by the medical assistant and told what I could and could not discuss with my doctor.

 

[MrsPete]

Here's a related topic, which seems totally unfair to me:

- I had my first colonoscopy when I turned 50 -- being the first time, it was coded as preventative. They found polyps, removed them. I have a family history, so I wasn't surprised. They told me I'm now an every 5-year girl.
- I came back in at 55 -- but because they had removed polyps last time, this colonoscopy was coded as diagnostic. Diagnostic comes with a big, fat co-pay. Over $1500.
- Essentially this means that the people who need the services most have to pay more than those who are just being checked.
- It's not just colonoscopies: it's also true for mammograms and other screenings. How can insurance get away with this?

Important: I don't want anyone to read this and use it as an excuse not to have colonoscopies! People are nervous enough about these screenings. My complaints are JUST about insurance.
They found /removed more polyps in my second exam -- so I'm glad I had it done, even though it was expensive. I asked my doctor afterward, "I'm clearly a person for whom polyps are a problem. As long as I have a colonoscopy every 5 years though, they won't develop into cancer, right?" He said, "That's right -- as long as you have a colonoscopy every 5 years, we can manage your polyps. Something's going to kill you someday, but if you do your part, this won't be it."

 

[Dznypal]

Actually I’m in the same boat as mrs pete. One polyp the first time and that branded me as having a history. Went 5 yrs later and it was a total disaster. I guess I was a little fidigty so the dr kept pushing the fentanyl. It wasn’t doing anything so he gave me a little more and a little more finally when it worked all the fentanyl hit my system at once causing me to stop breathing not only once but twice. Good thing they had narcan

Hate to admit it but I can’t get myself to ever to back.