November 19, 2023
Christine Rogers of Wake Forest, North Carolina, didn’t hesitate when asked to fill out a routine mental health questionnaire during an exam last November.
Her answers on the form led her treating doctor to ask her about depression and her mood, and Rogers said she answered honestly.
“It was a horrible year. I lost my mother,” Rogers told his doctor.
After what Rogers estimates was a five-minute conversation about depression, the tour ended. She said her doctor did not recommend treatment or refer her for counseling services.
“It’s not like something I said to him triggered, ‘Oh my God, I’m going to prescribe you some medication,'” she said.
Then the bill arrived.
The patient: Christine Rogers, 60, public relations/communications worker provided by Cigna Healthcare as part of her job.
Medical Services: An annual wellness visit, which included typical blood tests, as well as a depression screening and discussion with a doctor.
Service provider: WakeMed Physician Practices, part of WakeMed Health & Hospitals, a Raleigh-based tax-exempt system with three acute care hospitals, outpatient care centers and hundreds of physicians in a range of specialties.
Total bill: $487, which included a $331 wellness visit and a separate $156 fee for what was billed as a 20- to 29-minute consultation with her doctor. His insurer paid $419.93, leaving Rogers with $67.07 in costs related to the consultation.
Which give: Rogers said the bill came as a surprise because she knows annual wellness checks are typically covered without cost sharing for patients as preventive care under the Affordable Care Act. And as part of an annual physical, patients regularly complete a health questionnaire, which can cover topics related to mental health.
But there’s a catch: Not all care that can be provided during a wellness visit is considered free preventative care under federal guidelines. If a health problem arises during an exam that prompts discussion or treatment – for example, an unusual mole or heart palpitations – this consultation may be billed separately, and the patient may be required to pay a co-payment or a franchise for this part of the visit.
In Rogers’ case, a brief conversation with her doctor about mental health triggered additional visit fees — and a bill she was supposed to pay.
Rogers said she did not bring up the topic of depression during her exam. She was asked when she arrived to fill out the questionnaire, she said – and then the doctor brought it up during her exam.
The Affordable Care Act requires insurers to cover a variety of preventive services without the patient paying out of pocket, with the idea that such care could prevent problems or detect them earlier, when they are more treatable and less expensive.
The federal government lists dozens of services classified as preventive care without cost sharing for adults and children, such as cancer screenings, certain immunizations and other services recommended by one of two federal agencies or by the US Preventive Services Task Force, a independent group of experts in disease prevention.
Depression screening is covered in preventive care for adults, including when they are pregnant or postpartum.
Rogers requested an itemized bill from her doctor’s office, which is part of WakeMed Physician Practices. It listed a fee for the wellness visit (free for her), as well as a separate fee for a 20- to 29-minute office visit. Earlier, Rogers said, she had discussed the initial bill with her doctor’s office manager, who told her the separate charge, about $67, was for discussing the results of her questionnaire with her doctor.
For Rogers, it wasn’t so much about the $67 she owed for the visit, but rather a matter of principle. The distinct change, she said, was “misleading” because she was specifically asked about her mental health.
Additionally, annual physicals are intended to nip health problems in the bud, sometimes requiring a few extra minutes of attention – whether discussing symptoms of depression or palpating an abdomen for digestive issues.
Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University, agrees that this accusation seemed a bit exaggerated: Screening for depression “is now a recommended part of the physical exam.” annually,” she said. “It is implied that someone is reviewing the responses and making an assessment, and you should not be charged for that.”
Beyond the confusion of being billed for what she thought was free preventive care, Rogers wondered how the bill was calculated: Her conversation with her doctor about depression hadn’t lasted that long. a long time, she said.
A billing code for a 20- to 29-minute visit is commonly used in primary care, reflecting not only the time spent but also the complexity of the condition or diagnosis, said Yalda Jabbarpour, a family physician in Washington, D.C. DC. Robert Graham Center for Policy Studies, which studies primary care in the United States
Billing codes exist for other, shorter time frames, although they are rarely used except for the most minimal services, such as a quick question about a test result, she said.
Doctors said Rogers did the right thing, emphasizing that patients should be honest with their doctors during preventative visits — and not stay silent about problems because they’re concerned about possible cost-sharing .
“If you have an illness like depression, not only does it affect your mental health, but it can also have a significant impact on your overall medical health,” said Stephen Gillaspy, senior director of health and funding for health care at the American Psychological Association.
The resolution: Confused about being charged for a visit she thought was free, Rogers first called her doctor’s office and spoke with the office manager, who told her the claim submitted to her insurer was correctly coded for his visit. She then called her insurer to ask if an error had been made. She said her insurer said no, acknowledging that the doctor billed correctly.
Rogers paid the bill.
After being contacted by KFF Health News and with permission from Rogers, WakeMed Health System investigated the bill and said it was processed correctly.
“We share bills when a service provided goes beyond the preventative elements of a medical exam – in this case, beyond a positive depression screen,” said WakeMed spokeswoman Kristin Kelly, in an email.
However, Cigna Healthcare, Rogers’ insurer, sent him a new explanation of the benefits statement after being contacted by KFF Health News. The EOB showed that Cigna waived any costs to Rogers associated with the visit.
Cigna spokesperson Meaghan MacDonald said in a written statement that “the wellness visit was initially billed incorrectly with two separate visit codes, and has now been resubmitted correctly, so that There is no cost sharing for Ms. Rogers. We work with the doctor to ensure it is reimbursed appropriately.
THE insurer’s website says Cigna covers a variety of preventative services with no co-pay and encourages doctors to counsel patients about depression.
Shortly after receiving the new EOB, Rogers reported receiving a $67.07 refund from WakeMed.
Takeaways: Although many preventive services are covered under the ACA, the nuances of when a patient pays can be complicated and open to interpretation. It is therefore not uncommon for medical practices to interpret the term “preventive service” restrictively.
This creates a billing minefield for patients. If you answer a questionnaire that you sometimes suffer from heartburn or headaches, most doctors will look at your answers to assess the need for treatment. But should this incur additional costs? Other patients wrote to KFF Health News and NPR to express their frustration at being charged for conversations during an exam.
Additional time spent during a wellness exam discussing or diagnosing illness or prescribing medications may be considered beyond preventive care and result in a separate charge. But if you receive a bill for a preventive service that you expected to be free, request an itemized invoice with billing codes. If something is wrong, ask the doctor’s office.
If you are being billed for time spent on additional consultations, question it. You know better how much time the provider spent discussing your health problem than a billing representative. Then contact your insurer to protest.
Most importantly, be honest with your primary care provider during your annual physical.
Stephanie O’Neill reported the audio story.
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