FYI About Wellness Visits

I just wanted to post an experience that I had this past week.  It’s a little bit of an FYI and a little bit of a PSA.  Maybe it’s something that everyone else already knew.  Whichever category it falls under, I thought I’d share it so that no one else makes the same mistake in the future.

So last month, I went to the doctor’s for a normal check-up.  I hadn’t been to the doctor’s for my yearly check-up in almost 2-years and in that time, as everyone knows, some aspects of health care reform (aka “Obamacare”) went into effect.  I had heard from everywhere that in addition to free generic birth control, I’m also entitled to one routine check-up or “wellness visit” a year.  This visit is part of the preventative care overhaul and I believe all insurance companies have to start offering it now.  Essentially, you get one “free” check-up a year, where you don’t have to pay the normal office co-pay.  Having worked in the healthcare industry for 5 years, I know that there are always little stipulations to allow doctor’s offices to charge you and get around the “free” visits.  It can be something as stupid as saying “I need to schedule my yearly check-up” instead of “I need to schedule my wellness visit” when calling to make the appointment.  So, I called Blue Cross Blue Shield the day before my appointment to confirm that I was entitled to a co-pay-less visit that would be covered at 100%.  A very nice lady assured me that one wellness visit a year was covered under my insurance plan.

I went for my check-up.  The grumpy women who sit up front and normally won’t let you even say hello to them until you’ve forked over your co-pay let me sit down in the waiting room free of hassle.  I saw my healthcare provider, who is actually a physician’s assistant (PA).  She did the usual exam, which includes asking you how you feel and the like.  While she was feeling for swollen lymph nodes in my neck (routine), I remembered that I’ve had this lump in the back of my neck, at the base of my skull, that’s been bugging me for almost a year.  [I blogged about it back when I got the tempurpedic pillow, which worked for a little while, but now the discomfort is back.]  Her feeling around my neck reminded me of it, so I mentioned it to her.  She said she felt swelling there and therefore recommended an ultrasound to make sure all was well.  I said I’d do it as long as it was covered by my insurance plan.  She said they’d get it pre-approved and contact me once it was.  That was that, end of visit.  I got an otherwise clean bill of health and went on my way.

Last week, I received a bill in the mail from my doctor’s office.  They wanted me to pay my co-pay for the office visit on that date of service.  I was a little surprised, but again, having worked in the healthcare industry for 5 years, I know that mistakes are made when billing.  After calling BCBS to see why they weren’t covering the visit at 100% as promised to me by my president, the Blue Cross Blue Shield representative and Twitter, I was told that the PA who saw me did not code my visit as a wellness visit when the claim was sent in.  For anyone who does not know the lingo, when a claim is sent to a health insurance company, they basically request three things: chart notes, an ICD-9 diagnosis code and a billing code, which can be supplemented by certain modifiers which sometimes determine whether or not something will actually be covered.

As it turns out, my healthcare provider did not code for a wellness visit, but rather for swelling.  Upon speaking to the billing department at my doctor’s office, I learned that as soon as you bring up an ailment – no matter how big or small – to your practitioner, they have the right to use that diagnosis when billing your insurance company.  This automatically negates the purpose of the free wellness visit.  The very second that you say, “I’ve had this pain in my neck” or the provider finds something wrong with you, it becomes an office visit and is no longer a wellness visit.

The woman in billing confirmed what I feel is very important to let everyone else know:  The free wellness visits are pretty much only for people who do not need to see a doctor in the first place.  Sure, it’s a way to encourage people to go see their healthcare providers, but it’s only to make sure everything is on the up-and-up.  I had no idea that by answering the question, “Everything else is okay?” I’d be giving a $30 answer.  It’s only “free” if you don’t actually need medical attention.  I asked the woman in billing, “So then you should just lie and say everything is fine?”  Her response was, “But if you have a concern, then you’d have to make another office visit and pay a co-pay anyway.”  The logic makes sense, but the sentiment of a free check-up each year is pretty much null and void for me.

Anyway, I don’t write this post to be political or raise a fuss.  I just wanted to make someone else aware in case they didn’t know how the system works.  And maybe it doesn’t work like this and my PA was just trying to pull a fast one on both me and BCBS.  Either way, the moral of the story is to always be vigilant when it comes to healthcare, no matter what the president, your insurance company’s representative or Twitter tells you.

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