Why am I being Charged for my “FREE” physical? Saturday, Sep 1 2012 

Due to the Patient Protection and Affordable Care Act (PPACA), or commonly called “Obamacare”, Health Plans are starting to cover Preventive Medicine services at 100% with no copays, coinsurance or deductible. Unfortunately, insurance companies are not informing patients that dealing with medical issues during these preventive medicine visits will result in an out-of-pocket charge that could result in a co-payment, or a substantial out-of-pocket expense if they have not met their deductible. Insurance companies require all services to be itemized and coded appropriately. One of the primary reasons is to prevent the health plans from paying for services that are not covered. Providers cannot code problem visits as preventive because this would be insurance fraud and could result in the insurance company denying the claim, dropping the physician from their network, and/or, if a government plan, the physician can face imprisonment and fines.

This has resulted in patients becoming angry with their doctor’s offices. Many practices are trying to figure out how to deal with this issue. At my practice, we notify patients before their preventive visit by posting signs on the exam room walls and the medical assistant provides a written notification for the patient to sign that they understand the billing policy. We are also trying to have the physician alert the patient, during the preventive medicine visit, when their concerns become a medical visit and may result in an out-of-pocket expense to the patient. Depending on the severity of the patient’s concern, the physician may be obligated to address the medical issue because, if he didn’t, it could result in a bad outcome for the patient. For example, if the patient states that they have been dizzy and having terrible headaches, this could mean that the patient may have a brain tumor or other significant medical issue. If the physician ignored this complaint, it would harm the patient or could harm others if the patient were driving a vehicle and had an episode. In addition, this would easily become a malpractice lawsuit against the physician.

Some physicians have chosen not to do both a preventive medicine visit and a problem visit on the same day. If the patient is scheduled for a wellness visit and a problem comes up, the physician would either make the decision to change the visit to a problem-oriented visit and reschedule the preventive if the problem is high risk; or have the patient return to deal with the problem issue at a later date if the problem is a low risk. This method keeps the appointments separate and easier for the patient to understand the difference. The downside is that it requires the patient to come back for a second visit, taking additional time off work, to deal with something that could have been handled during one visit.

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Well Child Visit vs. School/Sports/Camp Form completion Tuesday, Feb 22 2011 

Most insurance companies will cover a well-child physical; however, the vast majority will NOT cover a “sport”, “school”, “camp” (etc.) physical.  There are several ways that this can be handled:

1)  If it is time for a well-child physical, perform the normal well-child physical and complete any paperwork during that visit.  The well-child visit should be coded using CPT 9938x-8839x series along with V20.2 diagnosis code.  If the child is eligible for this benefit, the claim should be paid.  Most health plans have a limit of one well-child visit per year.

2)  If the child recently had a well-child check and, if it is possible to complete the form using the information from the recent well-child check, go ahead and complete the form using that information.  This can be done free of charge.

3)  The last option is to have the child come to the office for a visit to complete the form and charge a CPT 9920x-9921x series code with a diagnosis code of V70.3.  The insurance company will NOT pay for this and the visit should be considered “Time of Service”.  The parent should be informed of this fact prior to the visit.