Re: Billing for annual physicals

Non-investing personal finance issues including insurance, credit, real estate, taxes, employment and legal issues such as trusts and wills.
Topic Author
porcupine
Posts: 1267
Joined: Thu Nov 04, 2010 11:05 am

Re: Billing for annual physicals

Post by porcupine »

My understanding is that an annual physical is a free visit to the doctor. However, my wife and I have both had issues with how we are being (over?) billed by our primary doctor who we've been visiting for nearly a decade now. Here is a brief summary:

For the last (nearly) two years, we have been on an HDHP. Both of us have a condition or two apiece (without going into details) that needs medication. They might be classified as 'pre-existing conditions' I guess.

in November, i set up my annual physical. When I got to the doctor's office, I was offered a sheet to fill out information about myself and my medical background. I specified on the form that I was there for a physical. The receptionist had noted (either verbally or on the form, I forget which) that if any medical condition is discussed, it would be treated as an office visit. :moneybag

When I filled my form, I responded to the question "is something bothering you right now?" with 'pain in the elbow.' When the receptionist informed me that it might be treated as an office visit, I crossed out that entire response (my logic is that I might as well use that money with the specialist instead of paying the primary to only tell me which specialist to go to!). When I met the doctor, I was asked about my pre-existing condition as part of the discussion (I did not bring it up). I replied that I had been seeing a specialist. I was told that I might want the dosage to be modified. I refused, saying that I had an appointment coming up in a few weeks.

A couple of weeks later, I look up the records with the insurance and am flabbergasted. I have been docked with an 'office visit' as well as a couple of other charges. I called the insurance and was informed that there was nothing they could do about it and that I would have to get it resolved with the doctor's office. Besides, for the couple of 'other charges' they informed me that they were not covered by insurance as part of the annual physical. I won't quibble about that because I would go with the doctor's infinite wisdom on those. My issue was with the 'office visit' designation.

Anyway, after pondering for a couple of weeks and getting invoiced by the doctor's office, I quietly paid up without fighting over it.

But then this week, wife goes in to have her physical. Almost everything happened similar to mine. When asked by the doctor, she said she had been seeing a specialist for her condition as well. But on the way out, they charged her - on the spot - about $150 towards 'office visit' yada yada yada. Needless to say, she was p*ssed.

Both of us - independently - then called the office back to complain. They are apparently going to look into it.

TLDR: Primary doctor charged husband and wife for 'office visit' when each had gone for an 'annual physical,' which is free per O*care; the HDHP patient is docked bokoo - pardon my French (spelling) - moolah for the former.

Now here is my question:

- will a patient with a pre-existing condition never be entitled to a free annual physical in the future? I mean, surely the pre-existing condition will come up during the annual physical and the doctor is well within his/her rights to ask the patient about it. But should he/she charge for it as an office visit?

- fortunately, the doctor did not call me back to go over the blood work. I had been given to understand that should I be summoned for one, that would result in an 'office visit' as well. Surely, discussion of blood work should be part of the annual physical. Subsequent visits, if any, should be treated as office visits, no doubt, but a meeting to go over blood work results??

PS: The purpose of this thread is to specifically discuss the financial aspect of an annual physical. Please feel free to remove any part of this post that fails to meet forum guidelines.

PPS: Instead of responding directly on this thread, should any of you prefer responding via PM, I would love to hear from you.
livesoft
Posts: 86076
Joined: Thu Mar 01, 2007 7:00 pm

Re: Billing for annual physicals

Post by livesoft »

We get blood drawn and lab results back BEFORE we go to physical, so that we can talk about blood chemistry at the physical exam.
Wiki This signature message sponsored by sscritic: Learn to fish.
Topic Author
porcupine
Posts: 1267
Joined: Thu Nov 04, 2010 11:05 am

Re: Billing for annual physicals

Post by porcupine »

livesoft wrote:We get blood drawn and lab results back BEFORE we go to physical, so that we can talk about blood chemistry at the physical exam.
Don't know about my wife, but I asked - and was told that I would get the blood work paperwork at the physical. Next time, I will insist on getting the paperwork for the bloodwork first. Whether at this doctor's or at a new doctor's!
User avatar
Munir
Posts: 3200
Joined: Mon Feb 26, 2007 3:39 pm
Location: Oregon

Re: Billing for annual physicals

Post by Munir »

I have never heard of free annual physicals. Is this something new under the Affordable Health Care Bill?
DSInvestor
Posts: 11647
Joined: Sat Oct 04, 2008 11:42 am

Re: Billing for annual physicals

Post by DSInvestor »

Munir wrote:I have never heard of free annual physicals. Is this something new under the Affordable Health Care Bill?
I have a HDHP and I just went for my wellness exam. I'll see in coming weeks how it works out. I assume I'll still get EOBs for the doctor visit and bloodwork. According to Blue Cross, I get one wellness visit a year and there is no out of pocket cost to me. That includes bloodwork too from what I understand. The doctor has to code the visit and the bloodwork a certain way.
Wiki
User avatar
wshang
Posts: 1239
Joined: Sun Feb 03, 2008 10:40 am

Re: Billing for annual physicals

Post by wshang »

For healthy adults between the ages of 18 and 65, The American Academy of Family Physicians (AAFP) recommends only these components of the traditional physical exam:

For men, a blood pressure measurement.
For women, add a rare Pap smear.
They have other recommendations including vaccinations, counseling, and rare screening tests; but none of those require a physical exam.

Annual routine exams have shown only to increase the number of diagnoses, but not to improve longevity. It is an open secret among those who are in-the-know, which ought to tell us something, since we see it is covered "for free" in O'Care. :moneybag

http://www.thecochranelibrary.com/detai ... iseas.html
User avatar
nisiprius
Advisory Board
Posts: 52212
Joined: Thu Jul 26, 2007 9:33 am
Location: The terrestrial, globular, planetary hunk of matter, flattened at the poles, is my abode.--O. Henry

Re: Billing for annual physicals

Post by nisiprius »

porcupine wrote:My understanding is that an annual physical is a free visit to the doctor....
My understanding is that the visit known as an "annual physical," during most of the time I've been getting them is actually a fairly expensive visit, typically involving several hundreds of dollars of physician's billing time and several hundreds of dollars billed for tests (EKG, around $100; blood panels, couple of hundred; etc.) My HMOs and other employer-sponsored insurance covered them. Medicare used to cover one "introduction to Medicare" visit that resembled the "annual physical." Now they also cover an annual "wellness visit" which is a considerably less than the traditional physical.

I am less sure about this, hope the docs will chime in, but it is also my understanding that the traditional annual physical is not a specific, fixed standardized list of tests to be done on every patient, but is a tree-structured exploration in which the things the doctor does, and what tests she orders, depend on what has been found already, both in previous visits and during the physical itself. Thus you and I might go to the same doctor on the same day for an "annual physical" and come out having had different procedures and tests performed.
Annual income twenty pounds, annual expenditure nineteen nineteen and six, result happiness; Annual income twenty pounds, annual expenditure twenty pounds ought and six, result misery.
livesoft
Posts: 86076
Joined: Thu Mar 01, 2007 7:00 pm

Re: Billing for annual physicals

Post by livesoft »

porcupine wrote:
livesoft wrote:We get blood drawn and lab results back BEFORE we go to physical, so that we can talk about blood chemistry at the physical exam.
Don't know about my wife, but I asked - and was told that I would get the blood work paperwork at the physical. Next time, I will insist on getting the paperwork for the bloodwork first. Whether at this doctor's or at a new doctor's!
That's not quite what I wrote. The bloodwork is done first, but the results go to the doc who gives it to the patient at the physical. That could be the same as "get the blood work paperwork at the physical" if the "paperwork" means "the results" on paper.
Wiki This signature message sponsored by sscritic: Learn to fish.
livesoft
Posts: 86076
Joined: Thu Mar 01, 2007 7:00 pm

Re: Billing for annual physicals

Post by livesoft »

There was a physician on the forum, biasion who wrote about how to increase billing simply by some of the things mentioned by the OP.
http://www.bogleheads.org/forum/viewtopic.php?p=512077

(Am I weird for remembering that thread?)
Wiki This signature message sponsored by sscritic: Learn to fish.
stlutz
Posts: 5585
Joined: Fri Jan 02, 2009 12:08 am

Re: Billing for annual physicals

Post by stlutz »

There are any number of ways that a PCP can code a visit. Some offices will be more honest than others. For some doctors, mentioning any kind of problem during this visit causes it to be classified as a "sick visit" as opposed to a "wellness visit." If you don't think your doctor is being honest, you should find another doctor.
pinecrest
Posts: 678
Joined: Fri Feb 15, 2013 9:51 pm

.....

Post by pinecrest »

.....
Last edited by pinecrest on Mon Feb 24, 2014 6:53 pm, edited 1 time in total.
Topic Author
porcupine
Posts: 1267
Joined: Thu Nov 04, 2010 11:05 am

Re: Billing for annual physicals

Post by porcupine »

livesoft wrote:
porcupine wrote:
livesoft wrote:We get blood drawn and lab results back BEFORE we go to physical, so that we can talk about blood chemistry at the physical exam.
Don't know about my wife, but I asked - and was told that I would get the blood work paperwork at the physical. Next time, I will insist on getting the paperwork for the bloodwork first. Whether at this doctor's or at a new doctor's!
That's not quite what I wrote. The bloodwork is done first, but the results go to the doc who gives it to the patient at the physical. That could be the same as "get the blood work paperwork at the physical" if the "paperwork" means "the results" on paper.
I was not clear. My bad. I meant paperwork to mean the list of tests that were ordered (as opposed to results of the blood draw).

Like nisiprius wrote above, my doctor is probably one where each patient likely gets to take a different set of blood tests. In my case, the doctor (or doctor's office) did not feel confident enough to order the tests until the doctor saw me.

- Porcupine
Topic Author
porcupine
Posts: 1267
Joined: Thu Nov 04, 2010 11:05 am

Re: Billing for annual physicals

Post by porcupine »

pinecrest wrote:
livesoft wrote:There was a physician on the forum, biasion who wrote about how to increase billing simply by some of the things mentioned by the OP.
http://www.bogleheads.org/forum/viewtopic.php?p=512077

(Am I weird for remembering that thread?)
Wow. That is an eye-opening thread.
Thanks livesoft! This is me right now! :oops:

- Porcupine
Traveler
Posts: 848
Joined: Fri Aug 30, 2013 9:07 pm

Re: Billing for annual physicals

Post by Traveler »

I've questioned the same thing. I would love to know the codes that are free/covered with a wellness visit and tell my doctor I only want and will only pay for those. I will call my insurance company and ask. I see no reason for them to do an EKG on my at my age and with no symptoms or significant risk factors for a heart condition, yet they do one every year. Seems ridiculous.
mbres60
Posts: 1303
Joined: Tue Jul 03, 2007 1:47 pm

Re: Billing for annual physicals

Post by mbres60 »

I am never asked to fill out paperwork. That sounds like a new patient. At my annual physical the doctor always asks if I have any issues. I don't remember if I have ever said I did. Sounds like you either need a new doctor or tell them of your dissatisfaction and that if they do this again you WILL look for a new doctor.
bluemarlin08
Posts: 1561
Joined: Wed Aug 29, 2007 12:18 pm

Re: Billing for annual physicals

Post by bluemarlin08 »

I had the exact same thing happened to me last year. I made it clear to the person I made the appointment with, seeing as they only do physicals at certain times, and told the nurse and the doctor. Well, got billed for an office visit. Blue cross told me it was how the doctor coded the visit. Called the office and they told me I discussed a number of medical issues, only because I was asked. They resubmitted the claim and it was taken care of. The office was somewhat difficult, the doctor was somewhat arrogant about the matter. Changed PCP.
Topic Author
porcupine
Posts: 1267
Joined: Thu Nov 04, 2010 11:05 am

Re: Billing for annual physicals

Post by porcupine »

mbres60 wrote:I am never asked to fill out paperwork. That sounds like a new patient. At my annual physical the doctor always asks if I have any issues. I don't remember if I have ever said I did. Sounds like you either need a new doctor or tell them of your dissatisfaction and that if they do this again you WILL look for a new doctor.
Not a new patient. Here is the second sentence of my original post:
However, my wife and I have both had issues with how we are being (over?) billed by our primary doctor who we've been visiting for nearly a decade now.
Maybe the word paperwork has different meanings/connotations. Be that as it may, I',m pretty sure I've had to fill this out every year, basically listing personal information, medical history, family medical history etc.

Let me reiterate - the doctor did not ask me (or my wife) if we had issues. She brought up the issues that we have been taking medication for.

Yes, it does appear that we need a new doctor. However, based on the thread that livesoft shared earlier, it looks like they aren't probably going to be any different.

Here's an analogy of how the modern doctor functions: Say you take your old beat-up car in for an oil change. Mechanic looks over car, knows that you are there expressly for an oil change, knows that you've needed to add oil once every couple of weeks for the last year to address its gaz-guzzling tendencies, asks you some questions about it; impresses upon you the importance of maintaining the oil level in the engine and how the engine might die if you don't keep it well oiled. Then dings you $50 on your way out because he imparted oil level maintenance related wisdom. How would you feel? Mechanics - especially those in dealerships - are already under the scanner for recommending work that is absolutely unnecessary (but even then, at least you are not being charged; only informed of what additional work is recommended). At this rate, I am afraid doctors will soon earn notoriety similar to lawyers and auto mechanics.

- Porcupine
jacoavlu
Posts: 1006
Joined: Sun Jan 06, 2013 11:06 am

Re: Billing for annual physicals

Post by jacoavlu »

I am a physician, but hospital based, not a primary care doc, so I can't provide any direct insight with regards to the billing/coding, but what I would do if I was in your shoes is to call the office, ask to speak with Dr. so and so's nurse, and ask her to take a message. Tell her you scheduled what you understood to be a preventative care/health care maintenance exam, that you believe you were charged for a different type of visit, that this impacts you financially because of your insurance, and you'd like the visit to see if it could be resubmitted to insurance. Call and tell the billing office the same thing.

One thing I will note, sometimes the type/level of visit is not mandated by the physician, but rather is determined by a billing/coding specialist from the physician's report that was generated from the exam. These are humans. They can and do make mistakes. Or maybe they're deliberately trying to upcharge. Either way, call them and complain.
User avatar
ejvyas
Posts: 773
Joined: Sat Apr 30, 2011 12:09 am
Location: Boston, MA

Re: Billing for annual physicals

Post by ejvyas »

I am using HDHP since the last ~ 3 yrs.

I have seen this is increasingly common practice unless you know the doctor or the office personnel. All my friends were charged extra and given lab orders that were diagnostic in nature even after they insisted the doctor to do just basic preventive tests during physical (examples are - thyroid test for male, simple question about vaccination, Vitamin D test) :oops:

Part of the problem is that doctors dont code the visit and a separate department does it. I always try to get the code from the billing department before I do any lab work and double check online whether it is coded as preventive or diagnostic. But that does not protect me from " :dollar Long office visit :dollar " or "short office visit" charges.

Unfortunately, there is nothing you or the insurance company can do about it. Just dont forget to rate the doctor or practice online and move along...
User avatar
White Coat Investor
Posts: 17409
Joined: Fri Mar 02, 2007 8:11 pm
Location: Greatest Snow On Earth

Re: Billing for annual physicals

Post by White Coat Investor »

Ahh...the unforeseen effects of mandating doctors to work for free. EMTALA anyone? Medicaid anyone?

Has anyone considered what the insurance company pays for 15 minutes of the doctor's time for a "wellness visit" versus 15 minutes of the doctor's time for an "office visit." You might think those two numbers were equivalent, but I bet they're not.

Here's a CMS document indicating what is supposed to be covered in a "wellness visit." I'm not a primary care doc, but that looks like 30-60 minutes worth of work to me. Unless the wellness visit pays 2-4 times as much as a 15 minute office visit, doing these visits the right way is a money-loser.

What is Included in an Initial AWV with PPPS?
The initial AWV
providing PPPS provides for the fo
llowing services to an eligible
beneficiary by a health professional:

Establishment of an individual’s medical/family history.

Establishment of a list of current prov
iders and suppliers that are regularly
involved in providing medica
l care to the individual.

Measurement of an individual’s height, we
ight, BMI (or waist circumference, if
appropriate), BP, and other routine
measurements as deemed appropriate,
based on the beneficiary’s medical/family history.

Detection of any cognitive impairment th
at the individual may have as defined
in this section.

Review of the individual’s potential
(risk factors) for depression, including
current or past experiences with depr
ession or other mood disorders, based
on the use of an appropriate screening in
strument for persons without a
current diagnosis of depression, which th
e health professional may select from
various available standardized screening
tests designed for this purpose and
recognized by national medical
professional organizations.

Review of the individual’s functional abi
lity and level of safety based on direct
observation, or the use of appropria
te screening questions or a screening
questionnaire, which the health professional may select from various available
screening questions or standardized questionnaires designed for this purpose
and recognized by national profe
ssional medical organizations.

Establishment of a written screening schedule for the individual, such as a
checklist for the next 5 to 10 years, as appropriate, based on
recommendations of the United States Preventive Services Task Force
(USPSTF) and the Advisory Committee on
Immunization Practices (ACIP), as
well as the individual’s
health status, screening
history, and age-appropriate
preventive services covered by Medicare.

Establishment of a list of risk fact
ors and conditions for which primary,
secondary, or tertiary interventions
are recommended or are underway for the
individual, including any mental health conditions or any such risk factors or
conditions that have been identified th
rough an IPPE, and a list of treatment
options and their associated risks and benefits.

Furnishing of personalized health advice
to the individual and a referral, as
appropriate, to health education or preventive counseling services or
programs aimed at reducing identifi
ed risk factors and improving self-
management, or community-based lifestyle
interventions to reduce health
risks and promote self-management and we
llness, including weight loss,
physical activity, smoking cessati
on, fall prevention, and nutrition.

Any other element(s) determined appropriat
e by the Secretary of Health and
Human Services through the National Coverage Determination (NCD)
process
1) Invest you must 2) Time is your friend 3) Impulse is your enemy | 4) Basic arithmetic works 5) Stick to simplicity 6) Stay the course
Jack
Posts: 3254
Joined: Tue Feb 27, 2007 1:24 am

Re: Billing for annual physicals

Post by Jack »

EmergDoc wrote:Ahh...the unforeseen effects of mandating doctors to work for free.
I fail to see where anyone was forced to work for free.
goaties
Posts: 542
Joined: Fri Jan 29, 2010 3:15 pm

Re: Billing for annual physicals

Post by goaties »

deleted
Last edited by goaties on Sat Nov 19, 2022 11:48 pm, edited 1 time in total.
richard
Posts: 7961
Joined: Tue Feb 20, 2007 2:38 pm
Contact:

Re: Billing for annual physicals

Post by richard »

wshang wrote:Annual routine exams have shown only to increase the number of diagnoses, but not to improve longevity.
Testing tends to increase survival rates (how long you live after a diagnosis) not how long you live. Unfortunately, many (including many doctors) don't know the difference between the two. It should be obvious that, all things being equal, the sooner you diagnose something the longer you live after the diagnosis, even if the diagnosis has no effect on longevity.

If I was going to live to 85 and something is diagnosed at 70, I'll live 15 years after diagnosis, but if it's not diagnosed until 80, I'll only live 5 years after the diagnosis. Survival rate is longer, but that doesn't really matter. Of course, in some cases, quicker diagnosis means quicker treatment, but, as you say, that doesn't lead to longer or better life as often as might be hoped.

Nonetheless, advocates of testing often cite longer survival rates as validation for testing.
User avatar
wshang
Posts: 1239
Joined: Sun Feb 03, 2008 10:40 am

Re: Billing for annual physicals

Post by wshang »

Physicians themselves cannot escape gaming of the system. My daughter went to the local ER for abdominal pain. I would have taken care of it but I had to go to work another hospital at the time. My wife ended up going with her on a light-workload weekday morning where a staff physician and a PA were on shift. My daughter had what I thought was a minimal work-up and was discharged symptom-free before noon, having been seen only by the PA.

The ER I should mention is staffed by a private group. I was surprised to receive the highest complexity code bill from them. When I called to complain that the physician had not thought it worth his while to get off his duff to examine her, and the case was seen entirely by the PA, they refused to back down, even knowing that I was a local physician.

You see, complexity coding is in the documentation of services - and this group has mastered the art of documentation for maximum reimbursement. Just like all other human endeavors, there is a whole range of actors. One can only hope there is less leeway to game the system and more incentive for the government to crackdown on those on the bleeding edge. (Of course there is the Libertarian view of government price setting, but I won't go there.)
Andyrunner
Posts: 856
Joined: Thu May 03, 2012 9:14 am

Re: Billing for annual physicals

Post by Andyrunner »

Its all about coding.

Actually, coders are a high demand job right now. I think its a very well paying six month degree and you can work from home.
User avatar
goodenyou
Posts: 3602
Joined: Sun Jan 31, 2010 10:57 pm
Location: Skating to Where the Puck is Going to Be..or on the golf course

Re: Billing for annual physicals

Post by goodenyou »

wshang wrote:Physicians themselves cannot escape gaming of the system. My daughter went to the local ER for abdominal pain. I would have taken care of it but I had to go to work another hospital at the time. My wife ended up going with her on a light-workload weekday morning where a staff physician and a PA were on shift. My daughter had what I thought was a minimal work-up and was discharged symptom-free before noon, having been seen only by the PA.

The ER I should mention is staffed by a private group. I was surprised to receive the highest complexity code bill from them. When I called to complain that the physician had not thought it worth his while to get off his duff to examine her, and the case was seen entirely by the PA, they refused to back down, even knowing that I was a local physician.

You see, complexity coding is in the documentation of services - and this group has mastered the art of documentation for maximum reimbursement. Just like all other human endeavors, there is a whole range of actors. One can only hope there is less leeway to game the system and more incentive for the government to crackdown on those on the bleeding edge. (Of course there is the Libertarian view of government price setting, but I won't go there.)
Behavioral Economics 101
pinecrest
Posts: 678
Joined: Fri Feb 15, 2013 9:51 pm

.....

Post by pinecrest »

.....
Last edited by pinecrest on Mon Feb 24, 2014 7:12 pm, edited 1 time in total.
likegarden
Posts: 3181
Joined: Mon Feb 26, 2007 4:33 pm

Re: Billing for annual physicals

Post by likegarden »

Annual physical is a separate billing code. With my BC HMO insurance it is free for me, but the doctor gets paid by BC. 2 weeks before this scheduled visit I get a form mailed to me by the doctor's office asking about my health. Since I got a script for this visit at the last visit I bring this script to a lab and get the required blood tests. Then I visit the doctor for my annual physical, he goes through the form I had filled out, checks my health and talks about it, then reviews my blood tests, also for high cholesterol. On the way out I get no additional billing, also nothing in the mail.
It seems that that doctor and office of the OP want to increase their billing, are muddling it up for that. I never had that experience, and it should not be that way. Perhaps it is time to change that doctor.

I also have a pre-existing condition, which is previously high cholesterol which is controlled via a statin. For that I go to a seperate office visit at the half-year date, which is preceded by another blood test, and the doctor reviews that during the visit.
User avatar
bengal22
Posts: 2146
Joined: Sat Dec 03, 2011 5:20 pm
Location: Ohio

Re: Billing for annual physicals

Post by bengal22 »

I had a similar issue with my doctor but the key is how they code it for insurance. Once I got that coding issue resolved with my doctor I have only had to pay a copayment of $25. I think the doctor is going to get his monies one way or the other but they just have to code it preventative visit. And yes I have a preexisting condition but they can still code it preventative.
"Earn All You Can; Give All You Can; Save All You Can." .... John Wesley
jcompton
Posts: 283
Joined: Mon Mar 10, 2008 12:59 am

Re: Billing for annual physicals

Post by jcompton »

Here are the services that healthcare.gov says are part of the PPACA zero-copay preventative services requirements: link
User avatar
Kevin M
Posts: 15787
Joined: Mon Jun 29, 2009 3:24 pm
Contact:

Re: Billing for annual physicals

Post by Kevin M »

Having seen this before (when I only got charged a copay), here's what I did last year (when I would have had to pay the entire amount for an office visit).

First, I indicated that I only wanted a physical (wellness exam) when I made the appointment. More importantly, when my doc first walked in the exam room, I explained that I only wanted a physical, because otherwise I would have to pay the full amount. I asked him what the parameters of the visit were to ensure it was coded only as a physical. He said that if we discussed any aches, pains, or any other specific condition, it would be coded as more than a physical. Therefore, when asked how I was feeling, I just said "fine".

Normally I would have discussed some other things with him, but I now have access to a clinic sponsored by the company from which I retired. So a few weeks later I went to that clinic, discussed my issues, and had a minor procedure performed. Normally I think they charge a $5 copay, but I guess since it was my first visit they didn't charge me anything.

I could have just had the physical at this clinic, but I did it with my regular doc for continuity, and so he would continue to approve refills for certain prescriptions. Since he knew I only wanted a physical, he didn't even ask about the conditions for which I get the prescriptions, but has continued to approve refills.

He ordered the normal lab tests. It was all covered by insurance except one test that was about $25, which I was glad to pay. I had previously discussed with my insurance company which lab tests were considered preventative, so I knew there could be some that weren't, so no surprise there.

By contrast, I had my dependant daughter take the same approach, but her doc (first time visit, same clinic as my regular doc) discussed a number of issues with her, and gave her several prescriptions. There were no charges to us! So, from this limited experience, it seems that doctors, even at the same organization, have some discretion in what they will do and still only code the visit as a physical.

Kevin
If I make a calculation error, #Cruncher probably will let me know.
Calm Man
Posts: 2917
Joined: Wed Sep 19, 2012 9:35 am

Re: Billing for annual physicals

Post by Calm Man »

Indeed, to be sure it is coded as a physical, one can do what Kevin did: say everything is fine. The problem is that a physical has ZERO value, zero. Except for a review of things that are problematic, the routine exam is worthless except for a blood pressure check annually, a cholesterol value every 5 years and being told to see the dentist twice a year (I'm not joking). The annual blood tests provides a bunch of lab values where invariably one or two are out of range and generates followup and anxiety. I assure everybody that there are very smart people working on this whole issue at the individual and system level and the "crazy" way things are done now will be anachronistic very soon.
User avatar
ejvyas
Posts: 773
Joined: Sat Apr 30, 2011 12:09 am
Location: Boston, MA

Re: Billing for annual physicals

Post by ejvyas »

Calm Man wrote:Indeed, to be sure it is coded as a physical, one can do what Kevin did: say everything is fine. The problem is that a physical has ZERO value, zero. Except for a review of things that are problematic, the routine exam is worthless except for a blood pressure check annually, a cholesterol value every 5 years and being told to see the dentist twice a year (I'm not joking). The annual blood tests provides a bunch of lab values where invariably one or two are out of range and generates followup and anxiety. I assure everybody that there are very smart people working on this whole issue at the individual and system level and the "crazy" way things are done now will be anachronistic very soon.
Part of the problem is doctors in US are trained to rely on labs, computers and machines to give accurate and up to date information about next steps. eg. In my home country, doctors can tell about the position of the baby by just feel. No need to do Ultrasounds every 2 weeks!
Traveler
Posts: 848
Joined: Fri Aug 30, 2013 9:07 pm

Re: Billing for annual physicals

Post by Traveler »

Healthcare is the only industry I can think of where I have no idea what I'm paying for until after I received the care and then received the invoice. I rarely get the opportunity to say I don't want to purchase a portion of the care they want to push on me. It's a ridiculous system that definitely needs overhauling. People who try to be mindful of their spending and consumption ultimately get screwed by the unknown and how things are coded. I like the idea of a cash only physician because he/she would probably tell you in advance how much the care will cost and I could decide if I want to pay for it or do without it.

For instance, my doctor always performs an EKG at my annual visit. I'm learning that is not the norm. This year I will insist I do not want it and will not pay for it. I am of no higher risk for a heart condition than the next person, have never had heart condition symptoms and therefore believe I'm being taken advantage of. If my doctor pushes back this year, I will simply find a new, honest doctor.
User avatar
Kevin M
Posts: 15787
Joined: Mon Jun 29, 2009 3:24 pm
Contact:

Re: Billing for annual physicals

Post by Kevin M »

Calm Man wrote:The problem is that a physical has ZERO value, zero.
So all of that poking and prodding is just for show?

And again, the value to me is that I can get my prescriptions refilled without having to pay to see my doc; in the past he has wanted to see me annually before refilling certain prescriptions. But it does seem like a farce since he didn't even discuss my conditions with me.

Kevin
If I make a calculation error, #Cruncher probably will let me know.
DTSC
Posts: 1194
Joined: Mon Oct 20, 2008 9:47 am
Location: Illinois

Re: Billing for annual physicals

Post by DTSC »

ejvyas wrote:
Calm Man wrote:Indeed, to be sure it is coded as a physical, one can do what Kevin did: say everything is fine. The problem is that a physical has ZERO value, zero. Except for a review of things that are problematic, the routine exam is worthless except for a blood pressure check annually, a cholesterol value every 5 years and being told to see the dentist twice a year (I'm not joking). The annual blood tests provides a bunch of lab values where invariably one or two are out of range and generates followup and anxiety. I assure everybody that there are very smart people working on this whole issue at the individual and system level and the "crazy" way things are done now will be anachronistic very soon.
Part of the problem is doctors in US are trained to rely on labs, computers and machines to give accurate and up to date information about next steps. eg. In my home country, doctors can tell about the position of the baby by just feel. No need to do Ultrasounds every 2 weeks!
I suspect OB's in your home country won't be sued for $5M when a baby gets stuck and ends up with cerebral palsy....
User avatar
wshang
Posts: 1239
Joined: Sun Feb 03, 2008 10:40 am

Re: Billing for annual physicals

Post by wshang »

Traveler wrote:my doctor always performs an EKG at my annual visit. I'm learning that is not the norm. This year I will insist I do not want it and will not pay for it.
Annual EKGs for Low-risk Patients Recommendation
choosingwisely.com
Don't order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.

There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low-risk for coronary heart disease improves health outcomes.
False-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment, and misdiagnosis.
Potential harms of this routine annual screening exceed the potential benefit.

Kevin M wrote:
Calm Man wrote:The problem is that a physical has ZERO value, zero.
So all of that poking and prodding is just for show?
What passes for sound, scientifically based medical practice in a pork funded environment amazes me. A provision was added to the O'Care specifying insurers were to base coverage decisions on previous breast screening guidelines rather than the 2009 USPSTF decreased mammographic recommendations and subsequent evidence to the contrary. Add the provision for annual "free physicals" - it's a disingenuous circus designed to increase utilization.
DTSC
Posts: 1194
Joined: Mon Oct 20, 2008 9:47 am
Location: Illinois

Re: Billing for annual physicals

Post by DTSC »

As a primary care doctor, this is how it works, at least in my practice.

It's true that annual physicals are actually not recommended, at least not for everyone. For example, a normal weight 25 year old man with no family or personal history of anything, who doesn't smoke or drink too much, and exercises enough, really has little reason to see me. Certainly not annually. However, it might make him feel (or more commonly, make his wife feel) that he is doing everything he should for his health. If a patient books an appointment, I'm happy to oblige. You generally don't know what family or personal history a new patient has, so I find out during the appointment and give recommendations based on my findings. If someone is young and healthy, I tell them to see me in 2.5-3 years. Why? Because if you don't see your doctor for 3 years, you are considered a new patient again for billing and insurance purposes. Also, a lot can happen in 3 years. I've seen patients gain 50 pounds in 1-2 years after a divorce.

Some guidelines recommend that screening/ preventive measures be done at the time of other visits, rather than at specific preventive appointments. So you give them a tetanus shot and offer cholesterol screening when patients come in for a twisted ankle or a respiratory illness. The flaw with this model, however, is that some patients, especially young men, might not feel the need to see a doctor for years, even decades, because they had no acute illnesses or injuries. But they might be living with sky high cholesterol and blood pressure and not know about it until it is too late. With women, this tends to be less common, since sexually active women get pregnant, or don't want to get pregnant, and this results in contact with the medical system.

I much prefer the term "preventive exam" rather than annual physical, because prevention is what I address at these appointments. This is individualized according to the patient's age, risk factors, lifestyle, etc. Topics might include substance use, seatbelt use, exercise, weight, HIV/STD's. Test might include screening for diabetes, high cholesterol, abdominal aortic aneurysm, mammogram, Pap smears. (Not an exhaustive list here). Insurance companies generally pay these visits (codes 99385, 99396) based on age and sex.

However, if the patient brings to the table issues outside of preventive topics, then a regular office visit can also be billed. If you come in for a preventive visit, but you also want me to examine and treat you for low back pain, adjust your blood pressure and diabetes medications, and talk to you for another 10 minutes about your insomnia, then I add on an office visit code (99212, 99213, and sometimes 99214) for addressing these extra issues. These codes are based on how much extra history I have to take, how much extra exam is performed, and complexity of medical decision-making which in turn is related to the number of problems or on the risk of the condition. It can also be based on time. For established patients, the time intervals are 10, 15, 25 minutes. If you come in and we addressed all your preventive needs, but we spend another 15 minutes talking about how bereaved you are because your mother died recently, then I add a 99213 code.

The problem is that many patients, probably for historical reasons, think they booked a "Complete" Physical and don't see why I should not be paid for spending another 20 minutes listening to them talk about the stress from their a**hole boss, their daughter being knocked up and their son being in jail for burglary and the fact that they are on their way to liver failure because they drink a fifth of vodka every night.

Conversely, I've had elderly patients with heart disease, high cholesterol, diabetes, high blood pressure and colon cancer complain that I never do a "Complete Physical" on them, even though I see them 3-4 times a year to tune up their various conditions. I then have to explain that we've done everything piecemeal over the year and all the screening tests were already done (or that I don't have to screen them for a condition which they have already developed).

To use a car repair analogy, a preventive physical is like a 50,000 mile maintenance appointment for a car. They might change your oil and air filter, rotate the tires, check the battery. If the car is spewing black smoke and the muffler is missing. I don't think anyone would expect the dealership to install a replacement muffler for free.
Last edited by DTSC on Thu Feb 13, 2014 11:32 pm, edited 1 time in total.
DTSC
Posts: 1194
Joined: Mon Oct 20, 2008 9:47 am
Location: Illinois

Re: Billing for annual physicals

Post by DTSC »

Calm Man wrote:Indeed, to be sure it is coded as a physical, one can do what Kevin did: say everything is fine. The problem is that a physical has ZERO value, zero. Except for a review of things that are problematic, the routine exam is worthless except for a blood pressure check annually, a cholesterol value every 5 years and being told to see the dentist twice a year (I'm not joking). The annual blood tests provides a bunch of lab values where invariably one or two are out of range and generates followup and anxiety. I assure everybody that there are very smart people working on this whole issue at the individual and system level and the "crazy" way things are done now will be anachronistic very soon.
I wouldn't say that a physical has ZERO value. It depends on the patient and situation.

I saw an otherwise healthy 35 year old 1 pack per day smoker for a physical 12 years ago. We spent most of the appointment talking about his smoking, and the fact that he has 2 young children. He stopped smoking that very day and started taking better care of himself. He finished a half marathon last year and is training for a full marathon this year. We'll never know for sure, but statistically, his stopping smoking should add a few years to his life.
DTSC
Posts: 1194
Joined: Mon Oct 20, 2008 9:47 am
Location: Illinois

Re: Billing for annual physicals

Post by DTSC »

Traveler wrote:Healthcare is the only industry I can think of where I have no idea what I'm paying for until after I received the care and then received the invoice. I rarely get the opportunity to say I don't want to purchase a portion of the care they want to push on me. It's a ridiculous system that definitely needs overhauling. People who try to be mindful of their spending and consumption ultimately get screwed by the unknown and how things are coded. I like the idea of a cash only physician because he/she would probably tell you in advance how much the care will cost and I could decide if I want to pay for it or do without it.

For instance, my doctor always performs an EKG at my annual visit. I'm learning that is not the norm. This year I will insist I do not want it and will not pay for it. I am of no higher risk for a heart condition than the next person, have never had heart condition symptoms and therefore believe I'm being taken advantage of. If my doctor pushes back this year, I will simply find a new, honest doctor.
I have no idea how much it would cost you when I order the test either. This is because a 3rd party (i.e. your insurance company, if you have insurance) might pick up all or part of the tab. Even if they pay none of it, they might have negotiated a discount for you, so your cost might still be lower than someone who has no insurance at all...
EnjoyIt
Posts: 8272
Joined: Sun Dec 29, 2013 7:06 pm

Re: Billing for annual physicals

Post by EnjoyIt »

goaties wrote:I would just like to note that these sorts of shenanigans occurred BEFORE Obamacare as well. In fact, it happened to me, last year, when I had my non-Obamacare-approved HDHP. Doctors are finding ways to game the system, since they feel that the insurance companies are not paying them enough.

Has anyone had any luck finding a doctor that accepts only cash (NOT a "concierge" doctor who demands hundreds/thousands upfront)? We have one in a town nearby, but that's all I can locate. Would appreciate pointers to a directory/website with this kind of info. I think we've all about had it with the for-profit insurance and medical care industry.

(edit: added word "only" before "cash")

Here you go. http://www.snaphealth.com This site allows you to pay upfront in cash/credit card without the insurance middleman.
A time to EVALUATE your jitters: | viewtopic.php?p=1139732#p1139732
tbradnc
Posts: 1532
Joined: Wed Apr 02, 2008 8:30 am

Re: Billing for annual physicals

Post by tbradnc »

I was fortunate enough to have had excellent insurance until 12/31/13. On 1/1/14 our HDHP-HSA started. We filled all of our prescriptions early, my wife moved up her mammogram, and I had my colonoscopy done as well prior to the HDHP kicking in.

I get my annual physical in January so so I arranged to have my blood work done in December so that it would be paid by the better policy and went in for my physical in January with my new health plan.

Physical was covered 100% - never got a bill. Lab was covered 100% under the old policy so bill there.

Also, my daughter's birth control is covered 100% under the HDHP - under our old, excellent plan BC had a co-pay of $15.

Another plus of living in a small town is getting to know your service providers. I regularly see our physician, his nurse, and the office manager around town. Whenever I call the doctor we're on first name basis and it's easy to get things done. I can even walk to our little hospital and pick up my labs and go over them myself before going to the doctor's visit.
User avatar
frugaltype
Posts: 1952
Joined: Wed Apr 24, 2013 9:07 am

Re: Billing for annual physicals

Post by frugaltype »

I haven't had time to read all the replies, but if I wanted to be sure I was only having the "free" annual physical, I would say that to the doctor. And if he or she slipped up and asked me about something that I thought might be outside that, I'd ask if that was part of that or not.

Personally, I think of my internist as the captain of the ship. I want her to know what's going on with the specialists. But I can afford regular medical care, so I'm fortunate.
Topic Author
porcupine
Posts: 1267
Joined: Thu Nov 04, 2010 11:05 am

Re: Billing for annual physicals

Post by porcupine »

There are two reasons why I have not responded to the responses on this thread:

- I have a lot to write
- I don't have the time to sit and write it all at one sitting :-(

In the meantime, let me share an article that my wife forwarded me. One thing is for sure - doctors have probably always been (for lack of a better term) 'superbilling, but we (non doctors) just haven't realized because it is all lost in the HMO jungle and we don't really pay. Even if we pay, no one goes after the doctors to get a reimbursement of a $20 or $25 co-pay.

- Porcupine
User avatar
Ferdinand
Posts: 16
Joined: Thu Mar 01, 2007 10:36 pm
Location: South Texas

Re: Billing for annual physicals

Post by Ferdinand »

Most insurance contracts offer one annual physical without a co-pay. Annual physicals are billed using preventive care codes. Physicians usually charge $200.00 for a preventive care visit and if you have insurance the bill goes to them. A visit typically includes a weight, height, blood pressure, body mass index determination, review of the personal, family, social history, a complete physical examination base on age and mainly counseling about diet, exercise, prevention of communicable diseases thru routine immunizations, prevention and screening of certain cancers base on age and family history.

Now the visit becomes complicated when a patient has complaints which the doctor needs to address or the physician finds an abnormality which requires further evaluation. In addition to the above services now the doctor has to offer a diagnosis and a treatment plan. Insurance carriers including Medicare has devised ways on how physicians can be adequately compensated for these services. So in addition to the preventive care code the doctor submits a E&M(office visit) code but attached to a modifier. See what we have to deal with here?

Most docs are not trying to game the system. We are just trying to be compensated for services that we offer. The usual charges for an office visit range anywhere from $90 to $150 base on the complexity and number of diseases and whether the patient is new or established. We do not get paid what we charge. So as anyone can see a preventive care visit is far more expensive than an office visit.
User avatar
yatesd
Posts: 1040
Joined: Sun Nov 03, 2013 7:19 am
Location: MD

Re: Billing for annual physicals

Post by yatesd »

Doctors shouldn't accept insurance or do physicals if they don't think they make enough money.

If I schedule an annual physical and the doctor believes we are covering something beyond the scope of the initial visit then the Doctor has the responsibility to inform the patient (and tell me how much more it will cost, just like going to the auto mechanic).

I just saw something in the news that irritated me this morning. It related a study that most patients should get basic tests at family doctors instead of at a Pharmacy quick clinic. Supposedly this is because the doctor better understands my needs due to our "special" relationship. :annoyed I have a stronger relationship with the Pharmacy cashier than I do with my family doctor (who on average spends 3.5 minutes with me). And yes I have insurance... :moneybag
Topic Author
porcupine
Posts: 1267
Joined: Thu Nov 04, 2010 11:05 am

Re: Billing for annual physicals

Post by porcupine »

yatesd wrote:Doctors shouldn't accept insurance or do physicals if they don't think they make enough money.

If I schedule an annual physical and the doctor believes we are covering something beyond the scope of the initial visit then the Doctor has the responsibility to inform the patient (and tell me how much more it will cost, just like going to the auto mechanic).

I just saw something in the news that irritated me this morning. It related a study that most patients should get basic tests at family doctors instead of at a Pharmacy quick clinic. Supposedly this is because the doctor better understands my needs due to our "special" relationship. :annoyed I have a stronger relationship with the Pharmacy cashier than I do with my family doctor (who on average spends 3.5 minutes with me). And yes I have insurance... :moneybag
With due respect, you don't appear to have read all the posts - this thread is specifically about when patients go in for a physical - and only a physical - and the doctor brings up pre-existing conditions; then enters codes equating to an office visit. ;-) When I started the thread, I thought ours was a unique situation, but it appears that it happens all over! :oops:

-Porcupine
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Billing for annual physicals

Post by dm200 »

It seems, from posts here, as well as my experience, that there are widely different situations experienced and practiced.

Last year (Kaiser Medicare) at my annual "health assessment", much of the appointment time dealt with a very recent issue, and the doctor ordered some new tests to address/diagnose that condition. There was no office visit charge and it was, apparently, billed as the annual health assessment (no charge to me).

What also occurred to me, as I read the posted experiences - is that not many years ago, many (of not most) health/medical coverage did not pay anything for an annual (or other) "physical". The common advice, back then, was to bring up some medical "issue" with the doctor so it could be coded not as a physical, but to address a problem/issue. Now, in some cases, we have the exact opposite situation.
Topic Author
porcupine
Posts: 1267
Joined: Thu Nov 04, 2010 11:05 am

Re: Billing for annual physicals

Post by porcupine »

dm200 wrote:It seems, from posts here, as well as my experience, that there are widely different situations experienced and practiced.
That goes without saying, though it does appear that enough folks are dinged - more than I had originally assumed when I made my OP.
dm200 wrote:Last year (Kaiser Medicare) at my annual "health assessment", much of the appointment time dealt with a very recent issue, and the doctor ordered some new tests to address/diagnose that condition. There was no office visit charge and it was, apparently, billed as the annual health assessment (no charge to me).
I wish we could have your doctor or someone like him/her.
dm200 wrote:What also occurred to me, as I read the posted experiences - is that not many years ago, many (of not most) health/medical coverage did not pay anything for an annual (or other) "physical". The common advice, back then, was to bring up some medical "issue" with the doctor so it could be coded not as a physical, but to address a problem/issue. Now, in some cases, we have the exact opposite situation.
Now that does ring a bell. I had assumed that the reason I had not had annual physicals earlier in life was because I was 'younger' but I now have a vague recollection of what you're talking about.

Somewhere along the line, I am pretty sure we were indoctrinated through HRs that having an annual physical was a good thing. In hindsight, I bet there was some nexus between the doctors and the insurance agencies that made for the change. I am not saying that each doctor voted on this scenario - just that at a high level, the planning doctors decided that this was a way to ensure enough 'churn' in the industry and the insurance agencies found away to keep hiking the premiums.

- Porcupine
ks289
Posts: 655
Joined: Sun Mar 11, 2012 12:42 pm

Re: Billing for annual physicals

Post by ks289 »

porcupine wrote:
yatesd wrote:Doctors shouldn't accept insurance or do physicals if they don't think they make enough money.

If I schedule an annual physical and the doctor believes we are covering something beyond the scope of the initial visit then the Doctor has the responsibility to inform the patient (and tell me how much more it will cost, just like going to the auto mechanic).

I just saw something in the news that irritated me this morning. It related a study that most patients should get basic tests at family doctors instead of at a Pharmacy quick clinic. Supposedly this is because the doctor better understands my needs due to our "special" relationship. :annoyed I have a stronger relationship with the Pharmacy cashier than I do with my family doctor (who on average spends 3.5 minutes with me). And yes I have insurance... :moneybag
With due respect, you don't appear to have read all the posts - this thread is specifically about when patients go in for a physical - and only a physical - and the doctor brings up pre-existing conditions; then enters codes equating to an office visit. ;-) When I started the thread, I thought ours was a unique situation, but it appears that it happens all over! :oops:

-Porcupine
It is very unfortunate that patients are put in a position without the necessary information to make informed decisions about cost/value. Prior posters have brought up very detailed information about the billing/coding system from the primary care practices' perspective, but it is unfortunate the system often does not align well with the interests of the patients.

You also brought up the issue from the inpatient side about observation vs inpatient status and the patient cost implications. What is driving this change from the hospitals' perspective is Medicare denying payment to hospitals if specific criteria for inpatient status are not met, hospitals' desire to avoid penalties for re-admission to the hospital within 30 days, and other issues.

That being said regarding your original post/concern- I do feel it is important for PCPs to review "pre-existing conditions" in order to appropriately care for patients. Besides being reponsible for these issues (even if specialists are involved), much of the value PCPs provide to patients' health stems from appropriately managing chronic medical conditions as opposed to complete (non-targeted) history/physical exams. Calm man may have overstated it, but I agree that in most patients (without localizing symptoms), exercises such as examining the eardrums or whipping out the reflex hammer and going from head to toe are very low yield.
Post Reply