There is nothing more frustrating than going to the doctor for an annual visit, assuming it is covered at 100% and then receiving a bill in the mail. We assume that our insurance did not cover our wellness exam, and that is why we are receiving it. It is possible that your insurance did cover your wellness visit at 100% however, you had more than a wellness visit. You may have had a problem-oriented visit as well. A wellness visit, also known as a preventive care visit or annual physical, is essentially a visit to get a snapshot of your health. Your doctor will ask you some questions, order lab work, and other tests based on the American Medical Association's recommendations for your age and gender. Usually, you will receive your results either in your online chart or in the mail. If you have anything abnormal in any of your results, the office may give you the results over the phone or ask you to come back into the office. These preventative care visits do not include any treatment of illness, injury, disease, or medication refills. It is these additional services that may trigger a balance on your account, which is why you receive a bill.
Why is this considered a separate visit?
Because the CPT Editorial Panel defines and manages all Current Procedural Terminology, aka CPT codes. We talked about them in the first article of this series. Every office service is assigned a code. These universal codes are used to communicate to insurance companies what service was done with your provider. It is your provider’s responsibility to ensure your medical chart matches the codes and vice versa. They can be audited by insurance companies and the government to ensure that visits are coded correctly. A wellness visit is separate from a problem-oriented visit. When your provider sends their claim to your insurance company, they are required to use both codes on their claim. To omit or add a code to a claim can be considered insurance fraud and can result in harsh penalties for your provider. That is why your provider will send both codes to your insurance.
When your provider sends both codes to your insurance company, your insurance company will adjust the claim against your benefits. If your insurance covers your wellness exams at 100%, even if you have not met your deductible or you have a copay, then they will pay that code at 100%. However, if there is an additional code for a problem-oriented visit, your insurance company will pay their portion based on how much of your deductible you have met and/or your copay. It is this second code that may cause you to receive a bill.
What wellness services are covered?
What is covered by your insurance varies by insurance company. The best way to know what your insurance considers preventative care is to go to their website and review their policy. At the bottom of the this post you will see links to the preventative care policies from three major insurance plans. IF YOU HAVE MEDICARE, TRADITIONAL WELLNESS VISITS ARE NOT COVERED, however, you are allowed a welcome to Medicare visit and a yearly wellness visit that is slightly different than traditional ones. If you would like a complete list of Preventative and Screening services for Medicare members you can click HERE. There you will find more links that explain your Welcome to Medicare visit and your Yearly “Wellness” Visits.
Anything discussed beyond these items is considered a problem-oriented visit. You may have heard a medical office refer to them as “sick visits” or “medicine check visits." For example, if you were scratched on Wednesday by a cat and the scratched area turns red and you think you need to see a doctor but you want to wait until Friday because you have an annual exam scheduled that day, then you are actually having two visits at one time. (That was me, last week). After the annual appointment, the provider examined the scratch, made a medical decision, created a treatment plan and implemented it. In my case, after examining the scratches and asking me some questions, he prescribed an oral antibiotic and a topical one. There are different levels of problem-oriented visits and this one was low-complexity so the additional code for the procedure was a low-level office visit.
Diagnostic test vs Screening test
A diagnostic test is different from a screening test and may not be covered at 100% by your insurance company. A diagnostic test examines an abnormality to diagnose it or review the current state of current health issue. For example, a female goes to a provider for a well woman exam. Due to the patient’s age, it is recommended that they have a mammogram done. The doctor does a breast exam and does not feel anything abnormal and will order a screening mammogram. The facility will perform an overall mammogram and not focus on any particular area of the breast. They are merely confirming that there are no abnormalities in the breasts. This will be processed and paid by your insurance as part of your wellness coverage benefits.
However, if the provider detected a lump during the wellness exam, they would order a diagnostic mammogram. Their order will tell the facility where they felt an abnormality, and the facility will focus on that area. Because it is a diagnostic mammogram, your insurance will adjust it according to your standard benefits rather than your wellness visits.
What do you do if you receive a bill?
If you did have a wellness exam and you discussed medications, ongoing illness or a new issue, then pay the bill. If you believe you only had a wellness exam, call the office and ask them to pull your chart and tell you what they consider to be a separate visit. Sometimes we forget we discussed something other than the wellness visit. If you remember from our last article, your provider must send you an initial statement within 30 days of them being notified you owe a portion of the cost for that visit.
If you receive a bill from a lab or facility visit that was ordered by your physician at your appointment, call the number on the statement. Your provider cannot see the billing system from that facility nor are they able to see how your insurance processed the claim to that facility. The facility can review your account with you and tell you why you are receiving a bill.
It is to your benefit to review all claims that are processed by your insurance company. Most plans have an app or website that allow you to see any claims processed.
Here are three common reasons your wellness claims are not being covered at 100%.
- Not a covered benefit. Call the entity that sent you the bill and ask them what service was not paid. Review your insurance company’s wellness policy and see if it is a covered benefit. If it is covered, call your insurance and ask them to look at the claim and if they agree with you, ask them to reprocess the claim. Ask for a reference number and the name of the representative. Notify the facility that you called the insurance and they are reprocessing the claim. Give them the name and reference number of the call to your insurance company. You should see the claim reprocessed within 30 days.
- Maximum number of visits exceeded: Most, if not all, plans allow no more than one well visit per year. Check with your insurance for their specific policy. For example, you have a well visit June 6th, 2024. You have your next visit June 13th, 2025. Some plans calculate by the day and some by the month. Which means if they calculate by the day, they will cover the 2025 visit because more than 365 days have passed since the one in 2024. If they calculate by the month, then they will deny this claim because it occurred in the same month as the visit in 2024. If this happens you can call your insurance and they may appeal the claim for you and have it paid.
- Out of network: If your insurance has a network of providers, your preventative care and screens should be performed by in network providers. Preventative care services are not urgent and do not warrant seeing someone that is out of network. When your provider schedules a test at a separate facility, call you insurance and verify that the facility is in network with your plan.
This post is meant to be an overall general view of well visits vs problem-oriented visits. There are exceptions in specific situations that warrant a more in-depth explanation. Comment below if you have any additional questions.
Wellness Policies
If you have a Medicare Advantage plan check with that specific plan. Often times they provide coverage for more services than traditional Medicare.
Add a comment to: Well visits vs Sick visits : Why am I receiving a bill?