When you go to the doctor for your annual exam, if you have insurance, you can expect that this visit will be fully covered. The I-Team learned that this is not always the case.
Patients report being charged for asking or answering typical health questions during their wellness visit. Elaine Gearheart is one of them. She told the I-Team during a wellness visit with a pediatrician at her medical provider, she brought up her child’s headaches and was later charged.
“It really surprised me,” Gearheart said.
“My daughter was complaining of headaches at school and was advised to keep doing the paper and maybe try a sugary drink,” she said.
“There was a $114 fee for an office visit.”
Gearheart showed us the invoice. His insurance covered most of the costs. So she only had to pay about $40. But when she called to dispute the bill, it didn’t work.
“They were good, they gave you treatment, and so it’s non-negotiable,” Gearheart said.
Another mom, who wished to remain anonymous, told the I-Team by phone that she was charged $70 more during her toddler’s annual checkup for discussing a few typical care topics health problems such as nocturnal enuresis.
The woman learned that the charges for “medical visits” on her explanation of benefits included a diagnosis of “urinary incontinence.”
These medical billing cases involved children, but we also heard from adult patients who had similar experiences but with different medical providers like Kris Ender.
“It was a normal physical check-up that is supposed to be fully covered,” said Ender, who said she was charged $78.65 for speaking with her doctor about a minor rash of eczema that she had during her annual preventive examination.
This was billed to Ender’s insurance as an additional office visit.
“Unfortunately, the current nature of our health care system’s billing is a fee-for-service model,” said Chris Van Haren, an independent patient advocate. A Better Way to Advocate for Occupational Health LLC.
Van Haren says what you talk about during your annual exam may cost you more. It all depends on your doctor’s policy.
“If you want to treat new symptoms, it goes beyond preventative care, it’s no longer prevention, it’s now a diagnostic visit,” she explained.
Wisconsin Hospital Association echoed this explanation and provided the response below to the I-Team:
Patients who have questions about the health care services covered by their insurance policy should seek this information from their health insurance company. Typically, preventative wellness visits are fully covered by health insurance. These visits aim to identify potential health problems before they arise.
In contrast, problem-focused office visits are treated differently by insurance companies and these services must be coded accordingly by health care providers. These services related to a current medical condition may result in out-of-pocket costs to the patient.
This distinction in the types of care patients receive can be confusing to patients, and Wisconsin hospitals work to educate those they serve about the costs associated with their services.
“It’s really difficult. It’s difficult to understand our system. It’s just as difficult for doctors and all providers to understand the system,” Van Haren said.
However, as a patient, you are not helpless. Van Haren suggests that before bringing up a health issue, ask your doctor if you’ll see any additional charges. Before your wellness visit, you can also call the billing office and ask them the same question. Finally, you can always fight the charges by appealing.
“It’s an uphill battle right now because everyone is short on time,” she said.
She emphasizes that you need to realize what you are facing. Many patients are postponing neglected medical visits, and COVID as a whole continues to strain our healthcare system.
For Elaine Gearheart, it’s not about the money, it’s about the principle. The nearly $40 charge upset her so much that she changed providers.
“I like to pay my bills on time, so I just ate the $40 and decided that was the last $40 they were going to get from us.”
