Replies

Roger that. I just paid $114 for my 100% covered yearly check-up. Must be common core math that they use.

If you have a pre-existing or a chronic on-going health problem (HBP, diabetes or chronic back pain for just a few examples) your annual physical may not be 100% covered (and this was even true before "Obamacare" for plans that 100% covered an annual preventative care exam, i.e. a routine physical - that was true for me in the early 2000's when I worked for a Pharma that had an outstanding, very high coverage and low cost, low deductible and minimal co-pay PPO health plan that 100% covered annual preventative care visits) especially if during your visit you complain or ask your doctor about an on-going or a new health concern or have to be further treated for or are tested and or diagnosed during your annual physical about an on-going or a new health issue; some of those charges and diagnostic tests may not be 100% covered under an 100% covered annual preventative care visit.

http://www.newsmax.com/Newsfront/Obamacare-healthcare-physicals-co-pays/2014/04/14/id/565370/

Doctors told the Journal that seniors have started canceling their annual wellness visits under their Medicare plans when they learn that if they mention a current health issue during the checkup they will likely be charged a co-pay.

Some doctors are even warning patients in advance of the problem and ask them to schedule two visits, one for the "annual" and another for their current health issue, according to the Journal.

Some insurers allow doctors to bill for their preventative and "non-preventative" services during the same visit using a special code called "modifier 25." But that can also lead to co-pays and confusion.

And

Many Blue Cross plans cover preventive care services without cost-sharing when you see a doctor that is in your health plan's network. Be sure to check the details of your plan before you make an appointment with a doctor. Sometimes, your doctor will order tests during your preventive care visit that are not considered preventive care. These tests may be subject to deductibles, copays and/or coinsurance. Your doctor may also treat an existing condition (or you may have symptoms of an illness at the time of your visit). Treatment or tests for that existing condition are not preventive care and are subject to deductibles, copays and/or coinsurance.

https://www.bluecrossmn.com/healthy/public/personal/home/livehealthy/lh-preventive-care

What you need to do is carefully review your IOB and your insurance billing statements and contact your provider's billing department to make sure they coded the annual visit properly, make sure they didn't code it as a general office or follow up visit in whole or only in part. Where I work, we have a "wellness initiative" that gives employees a discount on their employee paid portion (PR deduction) of our group health insurance premiums if they complete a combination of several things; one being an annual preventative health visit along with a combination of at least four others like getting an annual vision and or dental exam, completing a company paid and on company time on-site biometric screening (checking for HBP, cholesterol, blood sugar and BMI) and or completing an on-line heath assessment, getting a company paid or primary care provider flu and or pneumonia shot and or a preventative age dependent preventative screening such as a mammogram, colonoscopy, PSA test, etc, and or certifying that you are and have been a non-smoker for at least 12 months. You don't have to do everything listed to get the premium (PR deduction) discount but a combination of at least four of them in order to get the discount.

What we often run into on the annual preventative health visits is that if the provider doesn't code it for insurance billing as being a "preventative care visit" - if the employee is being followed up for or being treated for an on-going or a newly diagnosed health problem and the provider and or their billing department codes it as a "general office visit" or a "follow up visit", when HR/Benefits tries to confirm with our insurance company that the EE had an annual preventative health visit, it doesn't come up as such and often the employee complains that they were subject to a deductible or co-pay . (And FWIW, because of HIPAA, we are not privy any of the details or the results of the annual visit or the results of any diagnostic tests or of the biometric screenings or on-line health assessments - only that one was completed.)

What we tell our employees when scheduling an annual preventative health care visit, in order for it to be coded as such and 100% covered and counting for the wellness credit, is to make it very clear when scheduling the appointment and when checking out with the billing folks, that this is what it was. And if part of the visit included non-100% covered billing codes, i.e. not being part of a "routine annual preventative care visit" or if there were issues discussed with their primary care provider about existing or new health conditions or if further diagnostic tests had to be ordered, that that should be billed and coded separately from the "preventative care visit".

FWIW we also have the same issue for some employees getting mammograms or colonoscopies. If it is routine, age appropriate and truly "preventative", it should be 100% covered under our health plan. However, if an employee had been previously treated for breast cancer or was referred to get one before the age of 50 because of a family history or if they had pre-cancerous or cancerous polyps removed during a previous colonoscopy, subsequent mammograms and colonoscopies are now not considered to be "routine/preventative" screenings and thus are not 100% covered as being preventative.

I'm not making a case that they should or shouldn't be 100% covered but that is how it works.