That Free Wellness Visit Can Cost You a Fortune!
Preventive care is supposedly free under Obamacare. However, a recent article in U.S. News & World Report discussed the confusion that often occurs when people see their doctor for their annual “free” wellness visit. The problem: it is easy to inadvertently cross the line into non-free medical services that cause the wellness visit to be coded as something rather costly.
Patricia Jones thought she was getting the much-talked-about free physical under Obamacare when she went to see a doctor in May. But, she says, a few small things that happened during her checkup ended up making the visit cost more than $450.
Indeed, asking the wrong question during a wellness visit can sometimes result in the physician using a different billing code other than the “free” codes for preventive medical services.
In the process of answering questions from her doctor, Ms. Jones and her doctor turned a wellness visit into a diagnostic visit. Diagnostic visits are not covered under preventive care. Moreover, many people have high-deductible plans. A question or two, or agreeing to tests that are not medically necessary, can easily make that free wellness visit into a diagnostic visit that must be entirely paid for out of pocket.
Stop for a minute and think about the implications. A wellness visit that does little more than take your blood pressure and ask how you’re feeling is essentially worthless if your doctor is not allowed to act on anything he or she finds.
Of course, this was also true prior to Obamacare, when many insurers provided a no-cost annual physical. In the past the problem was that the wellness visit provided physicians with a relatively low reimbursement. If a higher level service was discussed, the billing code for the higher-paying type of visit was used.
I’ve always advised people they should talk to their doctor and explain they are in for their wellness visit. They should ask their doctor not to exceed the level of services that would turn the wellness visit into a diagnostic one. For instance, their doctor could note in their medical record to have certain diagnostic tests done at a future date when they are in for a non-wellness visit.
Best thing is to not examine the patient or do blood work, then you won’t find anything wrong.
Oh? but what would be the point?
It’s a shell game folks “Oh we care about your health so we’ll give no a no added charge visit, as long as they don’t have to treat you or diagnose something”.
Yeah, thanks a lot.
And it ain’t “free” to begin with.
If this so called FREE annual physical cost is $100 the insurance company will charge enough to cover the claim, administration and profit. So the $100 future expense will make your premium go up at least $120 annually and then the insurer hopes that you won’t schedule your FREE annual physical so it is $120 pure profit for the insurance company.
A self-employed guy doesn’t have time to see a doctor even if it’s “FREE”.
Even if a true wellness visit is “essentially worthless” it’s still free. Isn’t that a fair deal?
And if the patient turns it into a diagnostic visit, well, maybe that’s just evidence that Jonathan Gruber was on to something when he noted the stupidity of the American voter.
Devon are you advocating Insurance fraud?
There’s nothing fraudulent about explaining to your doctor that you don’t want any service that would preclude the visit from being billed as a wellness visit. If there is something the doctor has a question about, he or she can put a note in the medical record to check for something at the next regular visit.
From reading the article, it struck me that both the doctor and patient shared responsibility for the “free” wellness visit that turned into a $450 ordeal.
Her doctor ask about future childbearing. Her response “no, one child makes me tired enough.” The doctor then suggested a blood test to see why she was tired (presumably thyroid)?
Granted, patients should be on their guard and respond as though they are paying the bill (as opposed to saying “sure, it ain’t gonna cost me anything”). But, the doctor also knew the free wellness visit was moving well beyond the scope of a wellness visit.
If you think about it, this anecdote is characteristic of what’s wrong with our health care system. Patients who don’t care about cost because they think it’s free; and doctors who don’t control costs because it’s their revenue and because someone other than the patient is paying the bill.
Devon, maybe we should be training these patients on wellness visits not to volunteer any information and to answer the doctor’s questions with a question exactly like we train the tax-free HSA salespeople.
When the doctor asks about future childbearing. Maybe she should respond, “Are you putting the move on me? If you are that’s illegal and you could lose your license.”
Don’t ask more than 2 questions because these doctors will probably bill you extra if the visit goes over their scheduled 5 minutes.
You gest but it’s sadly true in many cases.
A year ago I went to the dermatologist for eczema due to dry winter skin. The doctor literally grabbed my file and examined it as he asked me about my coverage. When he discovered my deductible was (then) $5,000 including drug coverage, he suddenly offered me more economical options. These options included a wait-and-see attitude prior to performing a biopsy, a free sample of a dermatology steroid, and a coupon for an over-the-counter lotion. My only cost was $64 for an office visit and $52 for a prescription cream. I later discover the prescription cream could be obtained for $22 on Amazon. I can only imagine what the bill would have been if I had not indicated that I was sensitive to the costs.
When my Dad caught the doc doing Medicare fraud and confronted him he said, “Why do you care?”
There ain’t no such thing as a free lunch.
As a primary care FP physician at a large, well-run HMO with a good reputation, please let me advise you of the more common scenarios for the “free” “wellness visit” or “preventive health exam”:
1) The younger, new to the practice first time patient with multiple other issues which they have been saving up for their “free check-up”;
2) The older Medicare patient with multiple chronic illnesses on multiple meds, schedules one appointment a year for their “free” “Medicare Wellness Visit”, these multiple issues are addressed, and they bring up spontaneously (I can assure you, the last thing the timed-stressed provider wants to elicit is other complaints) brings up multiple other issues which they have been saving up for their “free” visit.
Both patients (who did not request extra scheduled time to address other concerns) are unconcerned about making other patients wait for their appointments (and often themselves complain about being kept waiting) and many complain about the extra charges.
But, Dr. V, can you really blame people for complaining they are not getting the free stuff they were promised?
Or for feeling that you are actually withholding that free stuff from them?
😎
Victor are you trying to say that wellness check ups are more important than checkups for ill patients? That is what one might believe based upon discouraging sick patients from seeing their doctor.
Al, I was actually just describing common scenarios seen w/ the “free annual visit.”
However, since you ask, my opinion is actually the opposite: ill patients’ actual health problems and concerns are are more important than ritualistic “check-ups.”
The scripted “preventive health exam” is of questionable benefit, other than in growing children and a few other situations (eg, pap smears).
One of the biggest time suck-ups is the “annual Medicare Wellness Visit.”
Primary care providers are spending so much time doing these types of visits that it steals appointment slots from caring for those who really need our help.
Thank you Victor for your clarification.
The wellness visit reminds me of the joke about the man who’s trying to get into the Yom Kippur service but he doesn’t have a ticket. He explains to the usher that he just needs to pass along an urgent message to someone.
Finally the usher relents and says, “Ok, you can go in but don’t let me catch you praying.”
“large, well-run HMO with a good reputation”
Uh huh. Is that the Tooth Fairy Network or The Unicorn Clinic? 😉
“large, well-run HMO with a good reputation”
“Uh huh. Is that the Tooth Fairy Network or The Unicorn Clinic?”
What do you think of Kaiser, Geisinger, and Group Health of Puget Sound?
They have no presence in Texas. I only know what I read and you have to take online reviews with a huge grain of salt.
To me, “HMO” and “large” are red flags. I avoid HMOs like the plague because of the added administrative burden and lower fees. I’m also limited in terms of who I can refer to.
I don’t think large size helps much. If your problem is out of the ordinary everything goes haywire while you get passed along to the right person.
In my personal experience when any company gets to a certain size it starts to bog down. In the Synvisc example I like to cite it wasn’t really 45 minutes of fighting. It was 15 minutes of fighting with several people and 30 minutes of being on hold being transferred. Their system can handle people who want Synvisc and were denied, but they aren’t prepared for someone who has found a vendor that costs less.
The same crap happened when we closed our company retirement plan. It took months of emails and phone calls to get it all sorted out.
While I’m no fan of HMO’s, I find it interesting that Kaiser garnered a market share of around 40% in Northern CA which suggests they must be doing something right there. A former college roommate owns a chemical testing business in San Francisco with about 40 employees. Kaiser has insured him and his employees for years. A number of years ago, he needed back surgery and was delighted with the care he received from Kaiser. At the same time, Kaiser bombed in several other places on the east coast and in the Midwest. So, what works fine in one place doesn’t necessarily mean it can be replicated in other places. Even the Mayo Clinic was not able to fully replicate its culture as practiced in Rochester, MN at its facilities in Jacksonville, FL and Phoenix, AZ.
I’ve stuck with regular FFS Medicare for myself even though it costs considerably more than a Medicare Advantage plan, many of which are HMO’s, because I want to ensure maximum provider choice, especially for care that needs to be delivered in a hospital setting.
I now work (as of last week due to acquisition and merger) at two of the three entities you mention above.
These really are pretty good places, for both patients and employees:
I wish more of the country had these options.
You make an interesting point. Thanks for sharing your perspective — it adds a lot of clarity to the discussion.
So basically, many patients view their “free wellness visit” as a freebie physician visit where they can have everything done for the year. They don’t understand a wellness visit to perform a discrete bundle of low level services.
Do patients report ahead of time they are coming in for their free visit? If so, are they informed what the limits of the visit are?
The ACA provisions about free wellness visits were like lipstick on a pig. There has always been a lobby which holds that prevention saves money, and so the final bill had to have some concessions to them.
I still maintain that there is something wrong with a system that forces patients to bargain with doctors and to be financially adversarial with their doctor. That cannot be good for healing, which is the whole point of medicine, right?
I think the proper question is this:
Would first-dollar Canadian style coverage improve the doctor-patient relationship and therefore improve health?
And if it does, is this worth the extra cost and extra bureaucracy and rationing that accompany a Canadian system?
I do not know the answer, incidentally.
Bob, don’t rich Canadians slip across the border and do their open heart surgery in Detroit so they don’t have to wait forever in line and die?
Where would Americans slip across the border to, Mexico City? Or maybe we could have surgery ships off the coast in international waters. But what about stormy weather and large waves? That has to make open heart surgery much harder or at least take longer.
I have thought about that.
In my scenario you’d go out into international waters and do surgery but there would also be regular cruise ship stuff like gambling, a pool, etc.
Or maybe just dock in Cuba. Try suing me for malpractice in Cuba.
Ron, build an offshore hospital on unused oil platforms in the gulf outside of US limits, but a quick helicopter ride to one of Texas’s top hospitals.
Native American Indian reservations are sovereign. I wonder what would prevent building a hospital on a reservation?
Right, we can have tunnels that go from the hospitals to the casinos. My beautiful Chinese sister-in-law was a dealer for a band of Indians. She says, “Those rich Indians really work poor little Chinese girls hard.”
She also calls hamburger – Grounded-Beef.
The only legal opinion I’ve seen was from the Florida AG in the 80s. A hospital on Seminole land would be under the jurisdiction of the State of Florida.
The only other reservation hospitals I’ve located are IHS projects.
NCPA did a blog on this 2 years ago BTW.
“first-dollar Canadian style coverage” is an oxymoron.
Oops. I read “first class”. But maybe that was the intended expression.
It’s called “upcoding” and it’s routine and frankly shady. My not 10 minute “consult” – with a local orthopedic doc – if you can call 10 minutes a consult – was uploaded from a Level I, maybe II to a Level IV (up to 45 minutes). Were it Medicare* that pushed if from $45-$90 to from $160-$190. Source: cms.gov For “fun” go check out that site and try to get a straight answer. There are 4 variables with 3-4 options each. Imagine walking into MacDonald’s ordering a burger then having to sit down with a “billing advisor”. 15-20 minutes later you will have paid anywhere from 3-20 bucks for the same, now cold, burger. THAT is the problem in healthcare.
And btw try asking your doctor upfront what he’ll charge. He’ll either have no clue at all (almost always) or be on the defensive or both. The inspires so much confidence and trust making for a truly positive and confident consult.
* my billing and payment was NOT through Medicare. That Level IV consult was billed at $273 and “discounted” to $218.52. Not bad. The doc’s office was billing like asbestos attorneys at over $1000 an hour.
I should add. I was also charged $338.93* (reduced to $262) for an x-ray (2 views) and and additional $35 (reduced to $15.08) to look at it. Yup an additional charge to LOOK at it. Isn’t that a given? An x-ray without a review is useless.
* who the hell makes up these prices? What if I had shorted the doc 93 cents? Would a collection agency chase me down? I’m betting yes.
“Yup an additional charge to LOOK at it. Isn’t that a given? An x-ray without a review is useless.”
There is a technical fee and a professional fee. The technical fee goes to the facility that does the xray. The professional fee goes to the person who reads the xray. They are not the same entity. When patients bring me MRI films to read is that supposed to be free? I don’t own the MRI business.
If I do an xray-guided procedure at a facility I might bill something along the lines of 77003-26, which tells the payer that I’m only billing the professional component. The facility bills 77003-TC for providing the xray machine and the tech to run it.
“What if I had shorted the doc 93 cents? Would a collection agency chase me down? I’m betting yes.”
If you deliberately short someone on their bill then you deserve whatever misery they inflict on you no matter the amount.
What are you using for morals? When did it become evil to try to collect on a contractual obligation?
Today’s word is H-Y-P-E-R-B-O-L-E
Oh. I thought it was “Deadbeat” or maybe “righteous indignation based on ignorance”.
What delightful bed side manner you have.
You think the Internet is your bedside?
“Imagine walking into MacDonald’s ordering a burger then having to sit down with a “billing advisor”.”
That’s because nobody sells food insurance.
“And btw try asking your doctor upfront what he’ll charge. He’ll either have no clue at all (almost always) or be on the defensive or both.”
That would be me I guess. I know what I charge but I don’t know what you’ll pay. Without knowing your coverage and benefits and how much you’ve spent so far this year it’s impossible to tell you what your cost will be.
I’m a partner in a physician-owned hospital. We give patients an estimate well before the surgery and sometimes they cancel. Other facilities blindside you with your out of pocket charges on the day of surgery. Then you’re in the quandary of opportunity cost – you took off work, your ride took off work, etc – are you going to walk out? IMHO that’s predatory.
So when you sit down with the “billing advisor” thank your doctor for providing that valuable free service that allows you to prepare in advance.
The only doctors who can reliably tell you what it will cost are plastic surgeons and perhaps the concierge/cash-only crowd. Note the absence of insurance for these services, just like McDonald’s.
Are you starting to see a pattern?
Indeed I am seeing a pattern. Insurance has removed all common sense and market incentives from health care. Look for things to get even more muddled. And I thank for your condescending response.
Your welcome. You deserved it.
I just ran into this getting a checkup billed to a BCBS employer policy, and it just highlighted what a racket hospitals have become, made worse by their Obamacare-driven gobbling up of almost all doctor practices.
A longtime feature of “first lets kill all the lawyers” jokes has been that class’s abuse of “billable hours.” Alas, consumers must now be alert to the same abuses from hospital-owned physicians who are under orders from to lard up those “annual checkups” with billable services.
Worse, they nickel-and-dime you with separate bills for every jot and tittle.
It’s really remarkable how thoroughly government has corrupted an industry that has such a profound impact on our lives.
Government hasn’t corrupted the industry. Government has been captured by it.
There are services that will sift through a bill and analyze it for overcharges.
I do consults for an insurance company to analyze whether the pain management services and bills submitted for personal injury cases were appropriate. Sometimes I see numbers where if you knocked a zero off they would still be too high. I saw one case where they billed for a special type of syringe but you don’t use that syringe for the procedure they did. It was $15 for a disposable plastic syringe they didn’t use. In another case they billed $2,000 for 15 minutes of IV sedation. They unbundle bundled services. I’ve never seen anything close to reasonable charges.
Were these workman compensation cases? I’ve heard there is a lot fraud and billing abuse in that area.
These are personal injury cases, mostly motor vehicle accidents. I just got another one today. MVA and back pain. Negative MRI but being treated for a pinched nerve, which in the OFFICE NOTE is estimated to cost $5,000-$7,000 for each epidural steroid injection. I’ve never seen prices in clinical notes before.
WC is a cesspool. It usually pays well, which attracts a certain crowd that is willing to wend its way through the obstacle course of regulations and denials and get as much as they can out of the system. Then dial in the fact that a lot of people are quite happy to malinger and collect benefits. I have literally had patients run the math for me to show how they’re better off on benefits as if that would make me understand their situation better.
I really don’t blame the insurers for a heightened level of antagonism and distrust in WC cases. Unfortunately, that chases out the good doctors and punishes the true sufferers.
Mike, Dr. Goodman today had an article in Forbes where he says that tax-free HSAs should only be available in employer-based health insurance and everybody else should pay taxes on HSAs like a Roth.
You are the only one who hates Hillary HMOs as much as me. Goodman trying to save employer-based health insurance, like everybody else (all non-profits), makes me sick. Let’s face it, parents should decide the insurance on their children instead of some uninformed employer who could care less if your child lives or is dead. I will probably be banned again for saying this but employer-based health insurance is the problem that the NCPA would prefer not to talk about because of donations. Hillary’s HMOs in Obamacare are driving Americans, particularly Texans, into HMOs like cattle. I blame Nixon and Ted Kennedy.
Ron,
I’m puzzled by the HSA recommendation.
He says “. . . third-party health insurance and individual self-insurance (say, by means of a Health Savings Account) must be on a level playing field under the tax law. If one gets a deduction, the other must get a deduction. If one gets an exclusion, the other must get an exclusion. If one gets a tax credit, the other must as well.”
But then he goes on to conclude that employer-based plans with an HSA should be pre-tax dollars but individuals should have to use post-tax dollars.
I think the playing field is already uneven if one person gets a policy using pre-tax dollars through work, but another person has to use post-tax dollars for an individual policy.
So I’m confused. I can’t follow the train of thought to that conclusion.
Why do you call these “Hillary HMOs”?
Micheal,
You are not confused, you think Goodman has faulty logic and you are correct. Goodman is trying to extend the monopoly of employer-based health insurance and it can’t be done. Parents should choose the insurance on their family and not some uninformed employer or Government bozo. This is so much money it is mind boggling.
Hillary and her Task Force tried to shove all Americans into HMOs during the Clinton Administration but failed. Documents showed that Hillary’s fall back position, if she failed, was to start with the children of America 1st and use an incremental approach to Socialized Medicine. Hillary’s KIDCARE or KIDPLOY was enacted in the BBA in 1997. Congressman Steve King (R-IA) calls KIDPLOY a cornerstone of Socialized Medicine. As you can see Obamacare only has HMOs in Texas, Florida, Iowa and many other states. I call them Hillary’s HMOs because it is true. A Brain Surgeon, Dr Miguel Faria, wrote about it in 1999 in Overdose of Socialism.
http://www.haciendapub.com/articles/overdose-socialism
Jack, that’s an interesting point. In the anecdote above from US News, Patricia Jones went in for a wellness visit. At some point her doctor picked up on something she said (feeling tired) and turned that into a diagnostic test. Surely the doctor knew the threshold for a wellness vs. a diagnostic visit was when a diagnostic test was ordered. Yet, there is no mention about whether she discussed this with her patient.
I’ve had the good fortune to have doctors who were very cognizant of costs. This may be true because I let them know I had an HSA. But not everyone is so lucky. Maybe (dare I say) the difference is influenced by who is paying the physician.
Can you give me some examples of when the payment source would influence a physician’s judgment in a way that’s adverse to the patient?
Adverse to the patient’s health? Or adverse to the patient’s wallet? There is a difference.
The argument against integrated HMOs back during the 1990s backlash against HMOs was that HMO-employed physicians were more beholding to their employer (the insurer) than to their patients. (I’m not saying it’s true, but that’s the theory behind the prohibition against the corporate practice of medicine in many states.) HMOs argued that their doctors were not ordered to ration care, just provide only necessary care (but not unnecessary care).
I have heard physicians employed by hospitals or hospital ERs say they have been pressured to order tests or admit patients that they thought didn’t need admitted. Former contract physicians at a hospital in Mesquite, Texas said they were told that 20% of Medicare patients were to be admitted. I’ve heard about decision-support software that would question the doctor’s order if certain thresholds were met but the doctor didn’t admit the patient. The docs complained these decision were being driven by (non-physician) administrators for financial reasons rather than clinical reasons.
By contrast, an independent physician who depends on me for payment may have an incentive to perform all the money-making services they can, but they have an incentive to keep me happy as a patient. A retired physician once told me what kept physicians honest in the days before insurance was they had to look their patients in the eye when they handed them the bill. It’s easier to gouge an impersonal insurance company than a patient you have a relationship with.
I see your point. I thought you were talking about whether the patient or the insurer was paying since you were talking about your docs/HSA considerations.
There is definitely production pressure for hospital-based doctors. They dangle this wonderful package before your eyes to rope you in, but then one day an administrator sits down with you, goes over your “bad” numbers, and explains why your pay will be cut next year.
Devon Herrick above: “Do patients report ahead of time they are coming in for their free visit? If so, are they informed what the limits of the visit are?”
Yes, they are so informed, repeatedly, both verbally and in writing:
On the general informational website itself, but also when they schedule the appt (whether on-line, by phone, or in person) and again when they check in, both verbally and in a printed handout.
I am not surprised in the least to learn that despite those efforts people still don’t get the message. For some people the whole world sounds like Charlie Brown’s teacher.
This is a public policy phenomenon with easily understood economics, though too few policy makers bother to understand it.
The well check is not meant to be a once-a-year free of charge appointment for people to get “free” help with their medical conditions, diagnosed or undiagnosed.
From a medical standpoint, the vast majority of yearly “well checks” are a waste of everyone’s time. They become a good use of time only when they catch something that might have gone undetected had the well check not occurred. And yes, the diagnosis and treatment must be paid for.
If treatment for that “something” turns out to be more effective and less costly due to its detection at the well check, then and only then does the routine “well check” save the “system” money and produce a better outcome.
Policy makers wrote the “free” well check into law simply to get people in the door on the chance that some of them will turn out to be the individuals that fit this scenario, with their care being less costly in the long run.
In the aggregate, the effect of the “free” check up is increased medical spending, even accounting for the small percentage of individuals whose underlying conditions were detected and treated for less cost than would have been incurred at a later stage.