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Insurance companies (payers) advertise “free” zero copay annual examinations to members. They infer no additional charges will occur but FAIL to mention that they define “wellness exams” very narrowly.
As payers define wellness, exams ONLY cover basic items that apply to ALL persons of your age. The proposed purpose of wellness is prevention and screening of potential problems; by definition, it is distinctly different from investigation of new specific concerns or treatment of ongoing issues.
Under your insurance company billing rules, If any issues need medical decision-making (evaluation and treatment assessment) by a licensed clinician, and these issues apply to you individually – not everyone your age and gender – then payers mandate in their contracts that these items be submitted on the billing slip -SEPARATE- from the wellness claim code. This separate line may appear as OFFICE VISIT or PROBLEM-FOCUSED visit and will generate the usual co-pay to see your primary physician.
Note: Doctors are required to document and bill each visit type separately, or based on your payer’s rules, insurance companies may consider doctors to have committed fraud. Most doctors strongly dislike the promotion of free annual visits by your insurance company which results in violation of your expectations, since most annual visits must have a co-pay as required by insurance billing rules. During your visit, we work diligently to give the finest care possible, to achieve our mission of providing the best primary care in the Treasure Valley. To ignore new threats to your health or to not treat ongoing individual medical issues (simply to avoid having an office copay) would be reckless and fall short of our commitment to you. Therefore, please anticipate at every annual visit to see both wellness & office visit codes on your EOB (explanation of benefits); although possible, very rarely do our patients have zero health problems to meet the insurance company definition of a “wellness-only” encounter.
When doctors prescribe refills, medical decision-making is always required. Elements involved in prescribing include:
For example, when refilling a blood pressure medicine, a typical physician’s thought process may go like this: what is today’s office blood pressure; is it at goal? What are the blood pressure numbers at home? Is the med causing side effects? Has the patient gained or lost weight which may influence the blood pressure goal? What are the comorbid (associated) conditions which may influence which blood pressure goal is chosen, or which class of medications should be used? Can I switch the current medicine to a different one that not only covers blood pressure but another condition the patient has (like kidney disease or palpitations or leg swelling)? Can I combine multiple medicines into a single combo pill to reduce the pill burden count? Which medicines have already been tried and abandoned due to adverse effects? Which medicines are contraindicated due to associated conditions? Is the blood pressure still high due to sleep apnea? (screen for apnea symptoms) Is the blood pressure still high due to excess alcohol use? (screen for alcohol intake) Does the insurance require a 30-day supply dispensing? Or a 90-day supply?
All these questions and more are considerations that should be weighed for every medicine refill. Clinicians who know you well and have years of experience can shuffle through these issues quickly and make it look easy, but medical decision-making is certainly required to do so safely and accurately.
Unless a person truly is one of the exceedingly rare people with zero medical issues, zero medications, and zero new concerns, then an office visit will be necessary at some point. The only question would be WHEN do you wish to have your office visit?
Options:
EITHER WAY, an office visit co-pay will be required by your insurance company. Your medical bill costs will be the SAME. It is important to understand that insisting upon a “wellness” only visit does not save you any money but rather costs you more money as it requires additional gas and time to visit later. Not only is a combined appointment type more efficient for you, it helps us to provide better care by taking a deep, focused dive on all your issues at once.
As mentioned above, when problem-focused issues need to be covered for health and safety, we are required to code them as such by the insurance company rulebook. When insurance representatives recommend changing codes, they have no idea what was discussed or documented; they are simply quoting their own rulebook without the details to know their statement does not apply in a given instance.
At times, patients may ask why a problem-focused visit claim needed coding when they did not ask the question or broach the topic, rather they say, “The doctor brought that up so I should not have to pay.” In such circumstances, know that our first duty is to deliver premier care to reduce threats to your well-being and health. When our medical training allows us to identify concerns that need to be addressed, it is our duty to address them in a timely manner. In particular, when many of our patients only wish to come to clinic once yearly, we would never have the opportunity to treat their specific problems if we restricted our care to prevention/ screening of wellness issues.
